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Full text of "U.S. Navy Medicine Volume 68, Number 7 July 1977"

VADM WUlard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM Paul Kaufman, MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 

MANAGING EDITOR 

June Wyman 

ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

C0NTRD3UTING EDITORS 

Contributing Editor-in-Chief: 
CDR C.T. Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT E.E. McDonald 
(DC); Education: CAPT J.S. Cassells 
(MC); Fleet Support: CAPT R.W. Jones 
(MC); Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.S. 
Anderson; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: LCDR J.T. 
Dalton (MSC); Naval Reserve: CAPT N.V. 
Cooley (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT R.W. Steyn (MC); Research: CAPT 
C.E. Brodine (MC); Submarine Medicine: 
CAPTH.E. Glick (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci* 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U-S- Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List, The following distribution is author- 
ized: one copy for each Medical. Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to; Editor, {J.S* Navy Medicine, Department of 
the Navy. Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C 20372. Telephone: (Area Code 202) 
2544253, 254-4316. 254-4214; Autovon 294-4253, 294-4316. 
294-4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35,. 



NAVMED P-508a 



U.S.NAVY 




1 From the Surgeon General 

2 Department Rounds 

NAMRU-5 closes in Ethiopia 
scientific achievement 



Volume 68, Number 7 
July 1977 



CAPT Brodine wins Conrad Award for 



5 On Duty LT Celso Bolet: A doctor of the mind 

6 Notes and Announcements 

NNMC trauma management symposium . . . Dental continuing education 
courses , . . Dental correspondence course revised . . . Uniform changes for 
Nurse Corps officers . . . Dental officers trained in casualty treatment . . . 
Basic emergency medical instructor training . . . Active duty and Reserve 
medical symposium held at NRMC Long Beach . . . Clinical neuro-otolaryn- 
gology course offered . . . MSC inservice selections for FY 77 

8 Letters 

9 NAVMED Newsmakers 

10 Scholars' Scuttlebutt 

ACDUTRA clerkships . . . Students tour NRMC Jacksonville 

12 Policy 

Safety in flammable, nonflammable and mixed anesthetizing areas . . . Fees 
for records . . . Instructions and directives 

17 Education and Training 

Understanding Goes a Long Way 

LT G.J. S pinks. MSC. USN; LT H.H. B elding LV. MSC. USNR 

18 BUMED SITREP 

19 Back When 

Hospital Apprentice Robert H. Stanley: Hero Lost in History 
ENSF.C. Brown. MSC, USN 

20 Clinical Notes 

Prepackaging Topical Ointments and Creams 
LCDR L.L. Karch. MSC. USN 

21 The Right Way to Thaw Meat 

22 Professional 

The Mediastinal Mass: A Continuing Challenge to the Thoracic Surgeon 
CDR J. A. Gibbons, MC. USN: M.J. O'Sullivan, M.D. 
CAPTR.G. Fosburg, MC. USN (Ret.) 

27 Pulp Response to Citric Acid Cavity Cleanser 

CAPT W.R. Cotton. DC. USN; R.L. Siegel. D.D.S. 

COVER: LT Celso Bolet (MC), a resident in psychiatry at the National Naval 
Medical Center, is training to meet the Navy's needs in this important specialty. 
Dr. Bolet tells why he chose the Navy and the specialty of psychiatry, beginning 
on page 5. (Photo by Milt Putnam,) 



From the Surqeon General 



Summer of the Doctor Drought 



THIS SUMMER marks the first real 
test of the all volunteer force Navy 
Medical Corps. Most of the physi- 
cians who joi ned us as a result of the 
doctor draft will have completed 
their service obligations, and many 
will leave the Navy. With their de- 
parture, Navy medicine faces what 
is perhaps its worst physician short- 
age in recent history. 

The problem will be most severe 
from late June through mid Septem- 
ber when almost all naval medical 
facilities will be short of their re- 
quired number of physicians. Medi- 
cal specialties with the severest 
shortfall are psychiatry, radiology, 
internal medicine, and family prac- 
tice. Although the situation should 
gradually improve over the summer 
as new physicians report for duty, 
we expect a shortage to continue 
longer than it has in past years. 

The shortage is expected to cause 
temporary reductions in services at 
most naval medical facilities. Full 
medical services must and will con- 
tinue for active-duty Navy and 
Marine Corps members. However, 
at some facilities it may be neces- 
sary to limit care for dependents of 
active-duty personnel, and for re- 
tirees and their dependents; some 
of these patients may have to be 
referred to civilian medical facilities 
under CHAMPUS. 

This difficult situation can be 
lightened considerably if all Medi- 
cal Department members show 
exceptional concern and patience 
when dealing with our health care 
beneficiaries this summer. Navy 
and Marine Corps families should 



be informed of the problem and, 
when necessary, helped to find 
alternate sources of health care. 
Through patient education pro- 
grams, they should be encouraged 
to develop good health habits and to 
avoid using medical facilities for 
minor illnesses. 

We can assure our patients that 
these temporary reductions in ser- 
vice are unavoidable. Individual 
medical facilities have drawn up 
plans for coping with the physician 
shortage with the least disturbance 
to patient care; here at BUMED, we 
will try to help seriously affected 
hospitals by assigning Reserve 
medical officers during active duty 
for training periods. While these 
efforts should help us through the 
immediate summer shortage, 
whether the Medical Department 
can return to its former level of ser- 
vice by fall depends upon the suc- 
cess of our physician recruiting and 
retention programs. 

In a crisis such as this, our great- 
est asset is the good will and coop- 
eration of our patients. When 
properly informed, the Navy family 
will be better able to deal with any 
necessary reductions in health care 
services, and can add their re- 
sourcefulness to our efforts to solve 
this problem. 




VADM Arentzen 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 68, July 1977 



Department Rounds 



Research 



NAMRU-5: 1965 - 1977 



Naval Medical Research Unit No. 
5 in Addis Ababa, Ethiopia, has 
been closed after nearly 12 years of 
operation. 

The research unit was one of five 
U.S. Government facilities ordered 
closed on 24 April by the Ethiopian 
Government. Immediately after the 
order, most NAMRU-5 American 
staff members and their dependents 
flew to Athens, Greece, but the 
unit's administrative officer and a 
chief hospital corpsman were al- 
lowed to stay a few days to close the 
building. Research data has been 
shipped to the Naval Medical Re- 
search and Development Command 
in Bethesda, or to the individual in- 
vestigators at their new duty sta- 
tions. 

NAMRU-5 had a staff of 69 
people: 17 military members, 2 U.S. 
civilians, 52 Ethiopians and a Brit- 
ish civilian. Commanding officer 
CAPT Raymond H. Watten (MC) 
and the seven officers and nine en- 
listed members who worked at 
NAMRU-5 have received perma- 
nent change of station orders to 
other activities. Several staff mem- 
bers have been assigned to the 
Naval Medical Research Institute in 
Bethesda, and one is now at 
NAMRU-2 in Taipei, Taiwan. 

Opportunities. Established in 
December 1965 as a field unit of 
NAMRU-3 in Cairo, NAMRU-5 be- 
came a separate command on 1 July 
1974, responsible for conducting re- 
search on infectious diseases in sub- 
Saharan Africa. Besides its base 
laboratory in Addis Ababa, 
NAMRU-5 operated a 22-bed clini- 
cal research facility at local St. 
Paul's Hospital, and a permanent 
field station at Gambela in the 
southwestern Ethiopian lowlands. 

In Ethiopia, NAMRU-5 research- 
ers found countless opportunities to 



investigate tropical and subtropical 
diseases. By conducting extensive, 
carefully documented disease sur- 
veys and laboratory-based research, 
NAMRU-5 scientists filled a vital 
need for epidemiological and medi- 
cal research on infectious diseases 
endemic to the country. 

Early NAMRU-5 investigations 
first documented the presence of 



chloroquine-resistant strains of 
Plasmodium falciparum existed in 
the country. 

Fever. A major research focus at 
NAMRU-5 was louse-borne relaps- 
ing fever, which strikes an esti- 
mated 6,000 Ethiopians each year, 
killing some 40% of patients who go 
untreated. NAMRU-5 scientists 
confirmed that the spirochete which 




NAMRU-5 staff member conducts tropical disease survey in Ethiopian lowlands 



Trypanosoma rhodesiense in Ethio- 
pia. NAMRU-5 scientists were the 
first researchers to isolate Rickett- 
sia conorii, which causes bouton- 
neuse fever, and Coxiella burnetii, 
the cause of Q fever in Ethiopia. 
Other firsts accomplished by the 
unit's investigators: the first report 
of Necator americanus (a New 
World variety of hookworm) infesta- 
tion in Ethiopia, and the first dis- 
covery of malaria-causing Plasmo- 
dium ovale in Ethiopia. NAMRU-5 
scientists also confirmed that no 



causes this fever is sensitive to a 
small amount of most common anti- 
biotics — but they also discovered 
that patients treated with these 
antibiotics have a potentially fatal 
Jarisch-Herxheimer reaction. 
NAMRU-5 researchers published 20 
papers on louse-borne relapsing 
fever, becoming recognized world- 
wide authorities on the disease. 

Malaria was also a central re- 
search topic at NAMRU-5. Re- 
searchers were conducting field 
evaluations to prepare for testing an 



U.S. Navy Medicine 



experimental malaria vaccine being 
developed at the Naval Medical Re- 
search Institute in Bethesda, and 
studying the natural immunity to 
malaria acquired as a result of infec- 
tions. 

Malaria was only one of many 
parasitic infections examined by 
NAMRU-5 researchers. Onchocer- 
ciasis ("river blindness"), a major 
health problem in the coffee-grow- 
ing area of southwestern Ethiopia, 
caught the attention of the scien- 
tists, who looked into the distribu- 
tion, prevalence and impact of the 
disease. Studies of 1,500 victims of 
elephantiasis revealed that in the 
Ethiopian highlands this parasitic 
infection is not caused by Wuchere- 
ria bancrofti, as had been believed. 
In 1967, NAMRU-5 scientists re- 
ported the first known cases of 
trypanosomiasis (sleeping sick- 
ness) in Ethiopia; within the next 
two years, this parasitic infection 
spread to epidemic proportions 
among scattered Anuak villages on 
the Gilo and Akobo Rivers of Uluba- 
bor Province. Throughout that time, 
NAMRU-5 survey teams combed 
the affected area to determine the 
distribution of the tsetse fly vector 
and the type of mammals which 
serve as reservoirs for the parasite. 

Disease vectors. NAMRU-5 re- 
searchers undertook a long-term 
program to study disease-carrying 
dipterous (two-winged) insects, 
which in Ethiopia transmit at least 
eight parasitic and viral diseases of 
man, including malaria and yellow 
fever. The goals: to map the 
distribution of dipterous insects 
known or suspected to carry human 
disease, assess these insects' vec- 
torial capacities by virus isolation 
and experimental transmission 
studies, determine the biting be- 
havior, seasonal incidence and 
breeding habits of species found to 
be major disease carriers, and 
establish colonies of those species 
for laboratory study. As part of this 
effort, NAMRU-5 researchers pre- 



pared a catalog of mosquitoes found 
in Ethiopia and established labora- 
tory colonies of four mosquito 
species. Progress was also made in 
determining whether yellow fever is 
transmitted by Erethmapodites sil- 
vestis, a mosquito widespread in 
the densely forested areas of south- 
western Ethiopia. 

Along with studies of disease- 
carrying insects, NAMRU-5 scien- 
tists conducted applied research on 
insect repellents, insect-attracting 
chemicals, and louse control. The 
researchers evaluated vulnerability 
to insecticides in field populations 
of mosquitoes, filth flies and black 
flies. 

Research workers at NAMRU-5 
identified several species of birds, 
bats, rodents, and amphibians 
which appear to transmit group B 
arboviruses. Arthropod-borne vi- 
ruses were studied by conducting 
serological surveys to determine the 
occurrence of past infections, and 
by isolating the viruses from natural 
sources; as a result, several genical- 
ly distinct arthropod-borne viruses 
previously unknown in Ethiopia 
were discovered. 

Natural lab. The results of much 
of this research are complete 
enough to be published — but it will 
be hard to continue the work outside 
Ethiopia, NAMRU-5's "natural lab- 
oratory, "say Medical Department 




NAMRU-5 researchers investigate in- 
fectious diseases at field station 



officials. "We retrieved all of the 
research data, and a number of 
publications will come from this 
material," predicted a spokesman 
at the Naval Medical Research and 
Development Command in Bethes- 
da. "We'll try to continue some of 
the research at other Navy labora- 
tories." 

Meanwhile, NAMRU-2 in Taipei 
and its detachment in Indonesia, 
NAMRU-3 in Cairo, and the Naval 
Medical Research Institute in Be- 
thesda, Md., will carry on the 
Navy's pioneering research on in- 
fectious diseases. 



CAPT Brodine: A Standout 
in Navy Research 



CAPT Charles E. Brodine (MC), 
since 1974 commanding officer of 
the Naval Medical Research and 
Development Command, has been 
awarded the Captain Robert Dexter 
Conrad Award — one of the Navy's 
highest honors for scientific 
achievement. 



The Conrad Award is given an- 
nually by the Secretary of the Navy 
to an individual who has made an 
outstanding contribution to Navy 
research and development. 

Dr. Brodine was honored for his 
contributions and achievements in 
managing the Navy medical re- 



Volume 68, July 1977 



search program. As a Navy physi- 
cian and researcher, he has man- 
aged research programs which pro- 
duced frozen blood technology, 
better ways to treat shock, new 
equipment to resuscitate combat 
casualties, and preventive measures 
to decrease health hazards during 
recruit training. Not only have 
CAPT Brodine's efforts helped re- 
duce mortality and morbidity in the 
armed services, but the results of 
his work are also being used in civil- 
ian health services throughout the 
world. 

Recent achievements under 
CAPT Brodine's leadership include: 

• a remote medical diagnosis sys- 
tem which enables shipboard per- 
sonnel to communicate with physi- 
cians at shore facilities. 

• a new hyperbaric research facility 
which will make possible research 
dives as deep as 3,400 feet. This 
laboratory will open in 1978. 

• a low-cost synthetic wound cover. 

• a noninvasive technique to esti- 
mate cardiovascular reserve in 
working or resting humans. With 
this technique, physiological heat 
exposure limits can be predicted for 
workers in many shipboard and in- 
dustrial occupations. 

• design and fabrication of a proto- 
type life support stretcher for evac- 
uating seriously injured casualties. 

• successful tests of techniques for 
long-term freeze preservation of 
blood platelets. 

• a new toxicology research pro- 
gram, in conjunction with the Air 
Force and the University of Califor- 
nia. 

• research into nerve regeneration 
and repair and into treatment of 
radiation injuries with bone marrow 
transplants. 

Urgent need. CAPT Brodine, who 
joined the Medical Corps in 1954, 
began his career in medical re- 
search in 1962, whjen he was ap- 
pointed director of the Bureau of 
Medicine and Surgery's frozen 
blood research project. At the time 
there was an urgent need for a bet- 
ter way to preserve, transport, and 
store large quantities of whole blood 
for treating combat casualties. Over 



the next two years, Dr. Brodine 
demonstrated that reconstituted 
frozen blood cells can be used to 
help resuscitate casualties in com- 
bat areas. During this time, bio- 
chemists and biophysicists collabo- 
rated to study the nature and pre- 
vention of freeze-thaw damage to 
red cells; also working on the 
project were physiologists and clini- 
cians who evaluated the functional 
state and clinical acceptability of the 
processed frozen red cell, and bio- 
engineers who helped design equip- 
ment to store, transport and process 
the frozen blood. 




CAPT Charles E. Brodine (MC) 

Honored for research achievements 

CAPT Brodine helped develop a 
complete system — from production 
through delivery — for getting frozen 
blood to field areas, and supervised 
the testing of frozen blood under 
combat conditions. He also assisted 
successful efforts to adapt a trans- 
portable field hospital for use as a 
forward-based laboratory where fro- 
zen blood could be processed close 
to the battle zone. For his work as 
director of the Frozen Blood Pro- 
gram, CAPT Brodine earned the 
Legion of Merit. 

Another of CAPT Brodine's note- 
worthy contributions to Navy medi- 
cine was his direction of research on 
traumatic shock in combat casual- 



ties. Under the Navy Shock Pro- 
gram, which CAPT Brodine started 
in 1963, problems raised by field 
physicians who had cared for com- 
bat trauma victims were studied in 
the Experimental Surgery Division 
of the Naval Medical Research In- 
stitute in Bethesda, Md. Research- 
ers concentrated on the pathophys- 
iology of hemorrhagic and septic 
shock. This program was extended 
to the field in 1965 when a surgical 
research unit was established at 
Naval Station Hospital DaNang, 
South Vietnam. 

Better equipment. During his in- 
volvement in the Navy Shock Pro- 
gram, CAPT Brodine recognized 
the need for better life support 
equipment. He later supported two 
important contributions in this area: 
development of a prototype portable 
volume-controlled respirator, and 
development, test, and evaluation 
of a medical suction pump. Both 
items will be used widely by the 
medical departments of the Navy, 
Army and Air Force. 

CAPT Brodine helped set up the 
Navy's program to screen recruits 
for sickle hemoglobin and glucose- 
6-phosphate dehydrogenase defi- 
ciency. Part of this research in- 
volved developing practical, inex- 
pensive ways to test Navy and 
Marine Corps recruits for these 
medical problems, which can be 
aggravated by the physical stress of 
military training and operations. 
Later, CAPT Brodine began an 
investigation into the incidence of 
rhabdomyolysis at Marine Corps 
Recruit Training Center, Parris 
Island, S.C. 

CAPT Brodine was born in Sioux 
City, Iowa, in 1925. He received his 
M.D. degree from Washington 
University School of Medicine, St. 
Louis, in 1953. He is an associate 
clinical professor of medicine at 
Georgetown University School of 
Medicine, Washington, D.C. 

The Robert Dexter Conrad Award 
was named in honor of CAPT 
Conrad, a primary architect of the 
Navy's basic research program and 
first director of research for the 
Office of Naval Research. 



U.S. Navy Medicine 



On Duty 

He's a Doctor of the Mind 



Seventeen years ago Celso Goi- 
coechea Bolet left his homeland in 
search of a freer way of life. Today, 
the 33-year-old Cuban immigrant 
believes he has not only found that 
way of life but "personal satisfac- 
tion and a feeling of camaraderie" 
as well. 

Now a lieutenant in the U.S. Navy 
Medical Corps, Dr. Bolet is a resi- 
dent psychiatrist at the National 
Naval Medical Center in Bethesda, 
Md. 

"I was a psychiatric intern at 
Jackson Memorial Hospital in 
Miami, when I attended a psychiat- 
ric convention," Dr. Bolet says. 
"The Navy had a booth there with 
several Navy physicians explaining 
various aspects of the Navy's medi- 
cal program. I listened to what they 
had to say, and decided that the 
Navy was what I was looking for." 

Obstacles. Dr. Bolet recalls that 
there were obstacles to overcome in 
his quest to practice medicine, 

"When I left Cuba, it was sup- 
posedly to continue my education in 
Jamaica. If I had told the Cuban 
government I wanted to leave the 
country for good, they would never 
have let me go." 

After receiving permission from 
U.S. immigration officials to live in 
the United States, Bolet contacted a 
relative who was residing in Miami. 

"I lived with an uncle in Miami 
for about a month and then moved 
to New York City," Dr. Bolet 
remembers. After holding various 
odd jobs in New York City for about 
nine months, he was reunited with 
his parents in Miami. 

"It took quite some time but my 
parents obtained permission from 
the Cuban government and immi- 
grated to the United States. Once I 
was with my parents in Miami, I 
enrolled at Miami-Jackson High 
School there. I completed my high 



school education and one year of 
college at Miami Dade College 
before I enlisted in the U.S. Army." 
Personalized medicine. After 
transferring to the inactive Reserve, 
Celso Bolet moved to Salamanca, 
Spain, to study at the University of 
Salamanca Medical School. He 
completed two years at that institu- 
tion, then transferred to the Univer- 
sity of Zaragosa, Spain, where he 
obtained his medical degree. 



time and understanding to help 
people with psychological problems, 
enabling them to function as they 
did before they acquired their prob- 
lem." 

Dr. Bolet adds, "Today people 
place less of a stigma on psychiatric 
patients than was the case years 
ago." He believes that psychiatric 
patients should be respected for 
undergoing treatment that should 
ultimately cure their problem. 




LT Celso Bolet (center) discusses a patient's chart with medical assistants at NNMC 



"I chose to specialize in psychia- 
try in my fifth year of medical school 
because I felt it was a more per- 
sonalized form of medicine," said 
the mustachioed physician. "I enjoy 
the intensity of the direct contact I 
have with my patients." 

Returning to the U.S. in 1972, Dr. 
Bolet became a house physician for 
Miami Dade General Hospital and 
Cedars of Lebanon Hospital, and 
completed his internship at Miami's 
Jackson Memorial Hospital. 

"More than some other medical 
fields, psychiatry demands total 
dedication to your patients," Dr. 
Bolet says. "It takes quite a bit of 



Satisfaction. In his capacity as a 
resident psychiatrist, Dr. Bolet pro- 
vides inpatient care to Navy and 
Marine Corps members and their 
dependents. "I enjoy my work," he 
says. "I enjoy the people I work 
with and I enjoy wearing the Navy 
uniform." 

"I'm sure there's some psycho- 
logical significance in getting satis- 
faction from wearing a Navy uni- 
form, but as far as I'm concerned, 1 
simply enjoy the feeling of knowing 
I'm helping defend this country's 
freedom." 

— Story by Lon Cabot. Photos by Milt 
Putnam. 



Volume 68, July 1977 



Notes & Announcements 



TRAUMA MANAGEMENT SYMPOSIUM AT NNMC 

The Robert B. Brown Trauma Symposium will be 
held 30 Sept-1 Oct 1977 at National Naval Medical 
Center, Bethesda, Md. The symposium honors VADM 
Robert B. Brown, MC, USN (Ret.), former Navy Sur- 
geon General and a national leader in surgery educa- 
tion. The latest advances in care of trauma patients will 
be discussed. 

Advance registration is required, and attendance is 
limited to the First 300 applicants. Active-duty military 
personnel, students, and residents do not pay the regis- 
tration fee, but must pay $10 for two lunches. All other 
attendees must pay a registration fee of $60, which in- 
cludes lunch. An additional fee of $20 will be required 
for the symposium banquet on 30 September. 

The symposium has been approved for 12 hours of 
continuing education credit. Retirement point credit 
will be given to eligible Reserve officers. 

For registration material and additional information 
write to LTJG Chris Edmond, MSC, USNR, Depart- 
ment of Surgery, National Naval Medical Center, 
Bethesda, Md. 20014. 



DENTAL CONTINUING EDUCATION COURSES 

The following dental continuing education courses 
will be offered in September and October 1977: 

National Naval Dental Center, Bethesda, Md. 

Operative dentistry 3-5 Oct 1977 

Oral surgery 17-19 Oct 1977 

Oral diagnosis and 

treatment planning 31 Oct-2 Nov 1977 



Eleventh Naval District, San Diego, Calif. 



Oral diagnosis 
Fixed partial dentures 



3-5 Oct 1977 
17-19 Oct 1977 



U.S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D. C. 

Current concepts of 

restorative dentistry 12-15 Sept 1977 

Preventive dentistry 25-28 Oct 1977 

Armed Forces Institute of Pathology, Walter Reed 
Army Medical Center, Washington, D.C. 

Forensic dentistry 3-6 Oct 1977 

Letterman Army Medical Center, San Francisco, Calif 
Removable prosthodontics 19-22 Sept 1977 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 



Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: Com- 
manding Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should 
arrive no later than six weeks before the course begins. 
Cross-country travel and travel from outside the con- 
tinental U.S. to attend dental continuing education 
courses generally will not be approved due to funding 
limitations. 



DENTAL CORRESPONDENCE COURSE REVISED 

The Dental Corps correspondence course, "Pharma- 
cotherapeutics in Dental Practice" (NAVEDTRA 13110- 
A), has been revised to follow the new text, Clinical 
Pharmacology in Dental Practice, by S.V. Holroyd (St. 
Louis: C.V. Mosby Co, 1974). 

In seven assignments, the course covers general 
principles of pharmacology, prescription writing, 
general and local anesthetics, sedatives and hypnotics, 
analgesics, tranquilizers, antibacterial agents, antihis- 
tamines, adrenal steroids, cardiovascular drugs, anti- 
septics and disinfectants, and fluorides. Special topics 
covered are emergency drugs, pharmacologic consid- 
erations for patients with systemic disease or common 
oral diseases, drug interactions, and drug abuse. 

Reserve officers will receive 14 retirement points for 
the course: 12 points after completing assignments one 
through six, and two points after completing assign- 
ment seven. 

Dental officers who wish to enroll in the course 
should submit form NAVTRA 1550/1 (Application for 
Enrollment in Officer Correspondence Course) to the 
Commanding Officer (Code 413B), Naval Graduate 
Dental School, National Naval Dental Center, Bethes- 
da, Md. 20014. 



UNIFORM CHANGES FOR NURSE CORPS OFFICERS 

A forthcoming change to Navy uniform regulations 
for male Nurse Corps officers eliminates the indoor 
duty white uniform and prescribes the tropical white 
long uniform for ward duty. Under this change, 
shoulder boards will be worn with the working uniform 
instead of collar insignia. Authorization has been given 
to make the change before distribution of the new regu- 
lations. 

In a recent revision to uniform regulations, two 
sentences were combined inadvertently, giving the im- 
pression that women may wear earrings with Navy uni- 
forms. Small, single-pearl earrings may be worn only 
with dinner or formal dress uniforms; earrings are not 
authorized for wear with any other Navy uniform. 



U.S. Navy Medicine 



DENTAL OFFICERS TRAINED 
IN CASUALTY TREATMENT 

Twenty Navy dental officers completed a casualty 
treatment training course held 4-8 April 1977 at Naval 
Regional Dental Center Norfolk, Va. In the course, 
dental officers learn emergency casualty treatment so 
they can augment medical efforts during combat. Simi- 
lar courses are held at Great Lakes, 111., and San Diego, 
Calif. 

Attending the course were the following Navy dental 
officers: CDRs A.W. Branon, M.R. Felger, and J.E. 
Isaacs; LCDR P.G. Lynch; and LT M.P. Larson. Naval 
Reserve dental officers who completed training were 
LCDRs D.D. Johnson and J.W. Shoaff; and LTs G.E. 
Bennett, R.J. Butz, S.J. Cathers, T. Elzie, C.S. Fuller, 
P.F. Getty, J.W. Hutter, R.M. Reavis, S.P. Selwitz, 
K.Z. Taylor, J. P. Webb, W.K. Wexel, and P.M. Wiley. 
Dental officers monitoring the course were CDR W.P. 
Dunn, Jr., and LCDR F.H. Ewald. 

BASIC EMERGENCY MEDICAL 
INSTRUCTOR TRAINING 

Thirty Reserve hospital corpsmen completed the 
Basic Emergency Medical Instructor Training Program 
held 28 Feb-11 March 1977 at Phoenix College, 
Phoenix, Ariz. The course is designed to provide Naval 
and Marine Corps Reserve programs with instructors 
qualified to teach basic emergency medical training. 
Two more classes scheduled for this fiscal year are 
filled. 

Five classes are being planned for FY78. Reserve 
corpsmen who want this training should apply for active 
duty for training through normal channels as soon as 
FY78 class dates are announced. 




Paramedic explains use of telemetry equipment 

Volume G8, July 1977 



ACTIVE DUTY AND RESERVE MEDICAL 
SYMPOSIUM HELD AT NRMC LONG BEACH 

Every year for the past three years, Naval Regional 
Medical Center Long Beach and Naval Reserve medical 
units in the Long Beach area have held a joint medical 
symposium. The one-day programs are conducted by 
regular and Reserve naval medical officers, and are 
open to all military and civilian medical personnel (in- 
cluding physicians, dentists, nurses, and paramedics). 

The third symposium, "Trauma," held 19 March 
1977, attracted nearly 500 attendees representing 123 
military and civilian hospitals. Topics discussed in- 
cluded emergency management of eye and limb 
injuries, bites and stings, the battered child syndrome, 
management of facial injuries, handling alcoholics in 
the emergency room, triage, and neurological and 
neurosurgical assessment of trauma. The symposium 
was accredited by the International College of Surgeons 
for eight hours of Category 1-AMA and Category 
1-CMA continuing education credit. 

RADM-selectee E.P. Rucci (MC), commanding offi- 
cer of NRMC Long Beach, encourages other naval 
regional medical centers and their local Naval Reserve 
medical units to organize similar programs to promote 
cooperation between Reservists and active-duty per- 
sonnel. 

CLINICAL NEURO-OTOLARYNGOLOGY 
COURSE OFFERED 

The University of Pittsburgh will offer its fourth 
continuing education course in clinical neuro-otolaryn- 
gology, 17-19 Nov 1977. 

Subjects to be covered are: hearing problems, bal- 
ance disturbances, review of pertinent anatomy and 
physiology (separate sessions for neurologists and 
otorhinolaryngologists), speech, swallowing, taste, 
olfaction, pain, facial nerves, and central nervous sys- 
tem complications. 

For registration information, contact Sidney N. 
Busis, M.D., Division of Continuing Education, 1022 
Scaife Hall, University of Pittsburgh School of Medi- 
cine, Pittsburgh, Pa. 15261. Telephone (412) 624-2653. 

MSC INSERVICE SELECTIONS FOR FY77 

The FY77 MSC Inservice Selection Board's recom- 
mendations for promotion to ensign in the Health Care 
Administration Section of the Medical Service Corps 
have been approved by the Bureau of Naval Personnel. 

The selectees are: HMCs Richard L. Bloomquist, 
Robert V. Collins, Robert J. Engelhart, Denzel E. 
Garner, Craig Jimerfield, Elwood L. Kephart, Bernard 
T. Miller, James A. Moos, Charles W. Neefe, Jr., and 
Herman J. Pagan; HMls Robert A. Acklin, Mark E. 
Babbitt, Thomas W. Burden, Henry M. Chinnery, John 
D. Faulls, Robert P. Owen, and Michael W. Ross; DTls 
Stephen F. Blacke, Lawrence E. Fowler, and Bobby D. 
Nipper. 



Letters 



RESERVE SPECIALTIES 

Please excuse my long delay in com- 
menting on "Reserve Specialty Support 
Capability," by CDR G.J. Hill, MC, 
USNR-R [US Nav Med 67(4):8, April 
1976], 

Two points interest me. One is the 
lack of identification of neurologists in 
the description of certified specialists. 
We are all apparently lumped with the 
psychiatrists, which is improper for 
planning as the tasks served are often 
totally unrelated. 

The second point is the lack of identi- 
fication of any specialists qualified in 
submarine medicine or diving medicine, 
while special comment is made for those 
in aviation medicine. No specialists are 
identified in occupational medicine, one 
of the largest operational medical fields 
within the military system. 

1 hope that these omissions do not 
reflect a lack of need or of concern for 
future planning, but are only an over- 
sight. 

CAPT H.W. Gillen, MC, USNR-R 
Wilmington, N.C. 

The author replies: Neurologists and 
psychiatrists are classified separately 
by the American Board of Psychiatry 
and Neurology. Unfortunately, I did not 
notice the notation in the directory when 
I reviewed the credentials of Navy 
Reservists who responded to the OP05S 
study. Access to the OP05R information 
is now closed because of the Freedom of 
Information Act, and for the same 
reason I have destroyed all my notes 
and computer sheets which related to 
that study. The information described 
by CAPT Gillen is available to BUMED 
(Code 36), and is utilized in planning. 

Space limitations made it impossible 
to tabulate all the capabilities and inter- 
ests of the reporting physicians, and my 
published report therefore does not 
include qualifications in occupational 
medicine. This information is available 
in the original OP05R data sheets; how- 
ever, it is probably incomplete since the 
responding officers exercised consider- 
able individual variation in the com- 
pleteness of their responses, and in 
some cases gave little more than their 
name, address, and major medical 
specialty. It is my recollection that rela- 
tively few indicated a special qualifica- 
tion in submarine medicine, and few or 



none specified a qualification in diving 
medicine, so I expect that an analysis of 
qualifications of Reserve medical per- 
sonnel for those specialties would have 
to be done on a new questionnaire. 

BUMED Code 36 adds: There are at 
present no Selected Reserve mobiliza- 
tion assignments in neurology, although 
proposed programs for FY78 will in- 
clude four neurologists. 

With regard to submarine and diving 
medicine, only six billets are shown in 
the Selected Reserve, all of them for 
captains in Program 1, the Submarine 
Forces Program. In contrast, there are 
160 billets for flight surgeon/aviation 
medical officers. Billet strength in 
Reserve communities is established by 
the major manpower claimant. 

Occupational medicine, a specialty of 
the shore establishment, is not cur- 
rently addressed in the Selected Re- 
serve, although in later stages in mobili- 
zation there will be a requirement for 
augmentation from the Individual 
Ready, Standby or Retired Reserve, or 
from the civilian community, 

TOP RECRUITERS 

We were extremely pleased to see the 
article on HMCS Larry DuFrain and his 
success in medical recruiting [US Nav 
Med 68(4):20, April 1977]. It is heart- 
warming to see a publication of this cali- 
ber give deserved recognition to the 
hardworking and sometimes maligned 
members of the Recruiting Command 
who are attempting to "man the fleet." 

We do not wish to impugn the cred- 
ibility of your sources. However, we at 
Navy Recruiting District New York feel 
most confident in stating unequivocally 
that we can "top" that. LT Robert R. 
Buckley, Jr., of the Navy Nurse Corps, 
was this command's medical programs 
officer for FY76, and he commissioned 
17 physicians and seven nurses for that 
same time period. 

While we give an enthusiastic "well 
done" to HMCS DuFrain for his out- 
standing efforts, we feel fully justified 
in claiming for LT Buckley the distinc- 
tion of being "top dog." If there is 
another "top dog" out there, let him 
show us the error of our way! 

CAPT Richard A. Stratton, USN 

Commanding Officer 

Navy Recruiting District New York 



According to Navy Recruiting Com- 
mand, LT Buckley did indeed recruit the 
largest number of physicians last year, 
so he is the top recruiter in that respect. 
HMCS DuFrain recruited 200% of his 
physician goal, and so was top recruiter 
from the percentage point of view, 
CRUITCOM did not specify which of the 
two men they consider "top recruiter. " 
They say both men are tops, and we 
agree. 

OUTMODED TRADITION 

VADM Arentzen's message about 
the realities of alcohol [US Nav Med 
68(4): 1, April 1977] is a courageous 
statement against an outmoded and un- 
healthy tradition. 

Another outmoded and unhealthy 
"tradition" is that of smoking. All phy- 
sicians are aware of the realities of 
smoking, for many of their patients 
suffer from smoking-induced diseases. 
The cost to the government, in terms of 
medical treatment, absenteeism, and 
disability compensation, is enormous. 
Yet, our patients see little evidence of 
our concern. The people they first see at 
the information desk are often smoking. 
They see physicians and other medical 
personnel smoking. They can buy ciga- 
rettes at the hospital's Navy Exchange 
or from a machine. Isn't it strange that 
our hospitals dispense both health care 
and health hazards? 

I hope that a future message will 
address the realities of smoking. 

CDR Lawrence R. Rubel, MC, USN 
Chief, Laboratory Service 
NRMC Great Lakes, 111. 60088 

A BUMED-sponsored campaign 
against smoking is in the works. 



Your letters help us keep US 
Navy Medicine responsive to 
your needs. Send letters to: 
U.S. Navy Medicine 
Department of the Navy 
Bureau of Medicine and 

Surgery 
23rd and E Streets N W 
Washington, D.C. 20372 



8 



U.S. Navy Medicine 



NAVMED Newsmakers 



When you're an optometry tech- 
nician standing a mere 4 feet 7 
inches and your patient's a towering 
7-foot Marine, how do you get his 
glasses from your hand to the 
bridge of his nose? It took some in- 
genuity, but HM3 Susie Sharp 
proved that no optical problem is 
out of her reach. She hopped on a 
counter top in the NRMC Camp 
Pendleton branch clinic and slipped 
LCPL Ken Cutler's specs into place. 
Obviously it was no mistake to give 
this resourceful hospital corpsman 
the height waiver she needed to join 
the Navy. 

"Faster than a disease-spreading 
rodent — more powerful than un- 
washed hands — able to leap tall 
sanitation problems in a single 
bound!!!" That's how the Atlantic 
Military Sealift Command magazine 
Mariner describes HM1 Mark Cook, 
one of only three preventive medi- 
cine technicians serving with the 
command. In Mariner's February 
issue, HM1 Cook reveals that he 
spends much of his time getting 
shipboard personnel to watch for 
potential hazards. When people 
begin to relax, he says, "they don't 
follow instructions, and trouble 
usually results." On one ship, crew- 
members forgot to flush out the 
pier's fresh water line. "What they 
got was water tasting like diesel 
fuel," says HM1 Cook, who cor- 
rected the problem before anyone 
became ill. 

Although LCDRs Charles Mc- 
Laughlin (MC) and Judy McLaugh- 
lin (MSC) are stationed at shore- 
based Naval Aerospace and Region- 
al Medical Center in Pensacola, 
they spend a lot of time at sea as 
owners of the 42-foot sloop Aggres- 
sive. Representing Navy Yacht Club 
Pensacola, the McLaughlins recent- 
ly took first overall in the Gulf 
Ocean Racing Conference, defeat- 
ing some of the toughest competi- 
tion in sailing. When not racing, 




HM1 Cook (standing): Diesel cocktail 

Chuck is a family practice physi- 
cian, while Judy heads the Physical 
Therapy Branch at the medical 
center. 

If you're a Medical Department 
runner, you have lots of company: 
ten NRMC Oakland staff members 
recently ran a grueling 26-mile 
marathon in less than 4 hours, with 
HM2 Terry Noyes finishing in 2 
hours and 52 minutes. Also in Cali- 
fornia, retired Navy surgeon CAPT 
Paul E. Spangler, age 78, earned a 
mention in Time magazine after 
finishing the San Francisco Bay to 
Breakers race — 7.6 miles — in just 
over an hour. Dr. Spangler is lim- 
bering up for the 1977 worldwide 
amateur runners' championships in 
Sweden. Not to be outdistanced was 
Reservist CAPT George J. Hill 
(MC), who joined SECNAV's 20- 
Minute Club after running three 
miles in 19 minutes and 42 seconds. 

A round of applause for: HN Dal- 
ton Lee who, by thinking clearly and 
acting fast, saved a choking victim's 
life aboard the USS Constellation 
. . . CAPT Norman V. Cooley (MC), 




McLaughlins: Tough competition 

director of BUMED's Naval Reserve 
Division, presented the Gold 
Wreath Award by the Navy Recruit- 
ing Command for excellence in re- 
cruiting . . . RADM Robert L. Baker 
(MC), recently elected assistant 
secretary of the American College 
of Obstetricians and Gynecologists 
... and LCDR Hunter A. McKay 
(MC), urology resident at NRMC 
Oakland, first prize winner in the 
Third Annual Northern California 
Urology Residents Seminar. 



Volume 68, July 1977 



Scholars' Scuttlebutt 



ACDUTRA Clerkships: 

A Close-Up Look At Navy Medicine 



Summer is upon us, and with it a 
surge in active duty for training 
orders. Navy scholarship students 
may serve their ACDUTRA period 
at other times during the year, but 
because of the traditional summer 
hiatus at most schools, students 
usually enter ACDUTRA assign- 
ments in the summer quarter. 

Some of you will be serving your 
ACDUTRA period this summer in 
clinical or research clerkships at 
Navy medical facilities. These clerk- 
ships are often your first contact 
with the Navy and we are well 
aware that your experiences during 
this time will have a lasting effect 
on your view of the Navy health care 
system as a potential career vehicle. 
Therefore, we make clerkship train- 
ing meaningful from the military as 
well as the professional point of 
view by devoting significant parts of 
the curriculum to active naval ser- 
vice and to military health care. 
Clerkship clinical rotations and re- 
search experiences are carefully 
planned to fulfill your professional 
and academic requirements, within 
the training command's resources 
and mission. 

Clerkship programs are con- 
ducted at naval regional medical 
and dental centers, naval hospitals, 
and Medical Department research 
activities in the United States and 
Puerto Rico which have the required 
training capabilities. Generally, 
first-year and second-year students 
will not be assigned to clinical clerk- 
ships; however, third-year and 
fourth-year students are eligible for 
both clinical and research clerk- 
ships. Clerkships are assigned ac- 
cording to the quotas established at 
training sites. Starting in 1978, a list 
of clerkships available at each train- 
ing facility will be published an- 
nually in a BUMED notice. In the 
meantime, scholarship students will 



continue to receive information on 
clerkships from the Naval Health 
Sciences Education and Training 
Command. 

The first receipt of ACDUTRA 
orders can be a dismaying event. To 
cast some light on the subject, we 
offer an annotated set of ACDUTRA 
orders (see chart). A more detailed 
description of your assignment will 
be provided with your orders. 

Students Tour 
NRMC Jacksonville 

' 7 was impressed with the morale of 
hospital staff members and of 
doctors serving on the USS Amer- 
ica." 

"I learned a great deal about what I 
can expect and what will be ex- 
pected of me. 

Those were some of the com- 
ments made by Navy scholarship 
students from St. Louis University 
School of Medicine after they spent 
the weekend of 6-8 May at Naval 



Regional Medical Center Jackson- 
ville, Fla., learning about Navy 
medicine. The two-day orientation 
emphasized operational medicine — 
new material for most of the 15 stu- 
dents, few of whom had ever seen a 
Navy medical facility. 

After touring the Jacksonville 
medical center and conferring with 
family practice physicians, the 
group headed for Naval Air Station 
Cecil Field. There they toured an 
aviation physiology training unit 
and the new branch clinic, and 
visited an S-2 submarine chaser 
squadron. 

The group then returned to Naval 
Air Station Jacksonville, where they 
were briefed on the P-3-C ASW air- 
craft and the duties of a P-3 squad- 
ron flight surgeon. The day ended 
with a party, where students could 
talk with Navy medical officers. 

At Naval Air Station Mayport the 
following day, the group toured the 
new branch clinic with CAPT Har- 
riet Simmons (NC), officer-in- 
charge, as their guide. A talk with 
the medical officer aboard the 
destroyer tender USS Yosemite and 
a visit aboard the carrier USS 
America wrapped up the indoctrina- 
tion trip. 

— Story and photo contributed by RADM 
Matthias H. Backer, Jr., MC, USNR-R. 




Students learn about duties of the P-3 squadron flight surgeon 



10 



U.S. Navy Medicine 



■THESE ORDERS ARE ISSUED BY THE COMMANDING OFFICER, 
NAVAL HEALTH SCIENCES EDUCATION AND TRAINING 
COMMAND (NHSETC), LOCATED AT THE NATIONAL NAVAL 
MEDICAL CENTER (NNMC), BETHESDA, MARYLAND, 
YOU ARE ATTACHED TO THIS UNIT 



YOUR GRADE, NAME, AND ADDRESS. 
HAKE SURE HSETC CODE 14 
HAS YOUR CURRENT ADDRESS SO 
YOU GET ORDERS PROMPTLY 



ACDUTRA LASTS 45 DAYS ■ 



PHYSICAL EXAM FORMS B8 AND 93 ■ 
MUST BE COMPLETED BEFORE 
REPORTING FOR DUTY 



MAKE YOUR OWN TRAVEL- 
ARRANGEMENTS. 
REIMBURSEMENT IS ON 
A RECEIPT BASIS. 



NAVAL FINANCE CENTER (NFC)- 

CLEVELAND, OHIO, 

STOPS STIPEND DURING ACDUTRA. 



DO NOT BUY A UNIFORM 
BEFORE FIRST ACDUTRA. 
REPORT IN JACKET AND 
TIE. UNIFORM 
INFORMATION GIVEN 
AFTER YOU REPORT. 



Volume 68, July 1977 



ACDUTRA ORDERS (formerly NAVPERS 1571/5 [2-731/ 

CNAVRE5 1571/5 {10-751 NAVCQMPT 2120 [Rev. 3-721 



' j ^erifwmi r i!W0 i 'e^F?(]PR^ r wmL health sciences education and p N 

TRAINING CQMnAND-i NATNAVMEDCEN, BETHESDA i HARYLAND E0014 / DO 



UNIT ATTACHED AND LOCATION 

NHSETCi NNMC-iBETHESDA^flD-SDOlM 



'-.RADE/RATE/NAME AND OFFICIAL ADDRESS 



PUila., Pa. /?/*/ 



NNUALAiBUTftA 1 

Loaves I I no group I a 



MOB BILLET <Oftlcai, Only 




ACCORDING TO PUBLIC LAW 92-426, 
ALL ENSIGNS, REGARDLESS OF 
PRIOR SERVICE, ARE PAID IN 
OFFICER GRADE #1 (0-1) DURING 
ACTIVE DUTY FOR TRAINING. 



SON 

N3mit7TTDH 



COMMAND DELIVERING ORDB^S (II alW Iran Oralnat 



03/ -77 -77? ~ 



ECU RITY clearance (b»ed on/ditB 






imv '<H training [ACDUTFJA 



_HS_ 



□ WITHOU 
PAV 



REPORT TOt 



□ □IFOT 
AUTH 



(Enlist Only) 



ACiP AUTH: (OTfita^ Only) 

_J OIFOPS ^J DIFDEN 

ACDi ASED: 




Commanding- Off/cea^ A/aval ^s^/onal Mspical 
Cea/7&?, Charleston \ South Carolina 29*03 
DeTACtt cw is august /9Z6. 

■ SEE ATTACHflENT FOR TRAVEL INSTRUCTIONS AND KEflUIREMENTS FOR PHYSICAL EXAM ^PHYSICAL EXAM 
TO BE CONDUCTED IN ACCORDANCE UITH CAHPTER Bi AR HD-SD1. 

IF THESE OHDERS ARE FOR 14 OAYS, TRAINING ACTIVITY WILL EFFECT OETAC 
EXCLUSIVE OF TRAVEL TIME. UB£JN COWPLETIdN OF ACDUTRA RETURN TO 



ildivtol ACOUTAA Of'"' 



7. MEMBER IS 



I I IS NOT I I 



ENTITLED TD BAQ WITH DEPENDENTS. 



3. COST OF TRAINING IS CHARGEABLE AS FOLLOWS: PaV/ALLOWANCES 

17T140S 223? POO 3M11L 1 OOOlbfl 2I> 000000 7r?7D0D0y,44T 



FRAVEL T^TTmnn^wr 

UNIFORM 7E7700GDXM4T 



74771000X441 



fRANSPORTATION AND MEAL T1CKET5 FURNISHED 



*PL ^2-4Eb PERMITS PAYMENT OF 01 ONLY. 
-ESTIMATED TRAVEL: $ f£a ESTIMATED PER VlZn:£/¥£& 

-FOR NFC CLEVELAND - STOP STIPEND ON J30 OUW jS7C» • 
START STIPEND ON I & A UG, 1970" 

^THE UEARING OF THE UNIFORM IS REQUIRED 



SIGNATURE OF ISSUING CiFriiCft 

G. S- BAKER 

LTJG MSC USNR 

BY DIRECTION OF THE 

COMMANDING OFFICER 



PHYSICALLY QUALIFIED FOR ACDUTRA 



PHYSICALLY EXAMINED AND QUALIFIED 

i- OH Release 



TRAINING ACTIVITY ENDORSEMENT 



GOVERNMENT QUARTERS AVAILABLE 



GOVERNMENT MESS AVAILABLE 



VOUCHER NO. 



YES NO 



sicWATUftE dP Medical oPftce* 



SIGNATURE OF MEDICAL, OFFICER 



DATE S. HH HEPOHTE'D 



SIGNATURE OF COMMANDING OFFiiEft 



DATE A HR DETACHED 



DrO. SYMBOL NO. 



NET AMOUNT PAID 



SIGNATURE or COWMAN DINt OFficEr 



SIGNATURE OF DISBURSING OFFICER 



-YOUR SERVICE DESIGNATOR 
IS ENSIGN 1975 



-SOCIAL SECURITY NUMBER 



lON JULY 1 , 1976, AT 8 AH, 
REPORT TO THE SPECIFIED 
COMMAND 



-ACCOUNTING INFORMATION 



-PHYSICAL EXAM IS NECESSARY 
TO REPORT FOR ACDUTRA 



■HAVE THE OFFICER OF THE 
DECK (ODD) SIGN YOUR 
ORDERS ON ARRIVAL 



-LIVING EXPENSES (PER DIEM) 
AUTHORIZED UP TO THIS AMOUNT. 
REIMBURSEMENT IS ON A RECEIPT 
BASIS. YOU ARE NOT ELIGIBLE IF 
BACHELOR OFFICER QUARTERS (BOQ) 
ARE AVAILABLE. 



Annotated Active Duly for Training Orders 



11 



Policy 



Safety Tips 



Safety in Flammable, Nonflammable and 
Mixed Anesthetizing Areas 



CDR John P. Swope, MC, USN, BUMED Code 416 



In the previous issue, US Navy Medicine offered a 
summary of a portion of the National Fire Protection 
Association standard, Inhalational Anesthetics (NFPA 
56A) that deals with general requirements for all hos- 
pital anesthetizing locations. In this issue, we cover the 
specific requirements in NFPA 56A for flammable, non- 
flammable, and mixed anesthetizing locations. 

FLAMMABLE LOCATIONS 

The prime hazard in flammable locations is combus- 
tion. Combustion can be either an explosion or a Fire — 
the difference is in the rate of combustion and the 
energy released. To produce an explosion or fire there 
must be: 

• Fuel or a flammable anesthetic agent. 

• Oxygen or another substance such as nitrous oxide 
which will support combustion. 

• An ignition source. 

In hospitals with flammable anesthetizing areas, 
flammable agents and oxygen are part of the anesthetic 
mixture and cannot be eliminated. Therefore, the only 
ways to prevent an explosion or Fire are to contain the 
explosive anesthetic mixture in certain carefully regu- 
lated "hazardous" areas and to eliminate sources of 
ignition such as electrostatic sparks, arcs from 
electrical Fixtures, and open flames. 

Containing the explosive mixture: All operating room 
areas from the floor up to five feet are considered to be 
hazardous because flammable anesthetics, which are 
heavier than air, drop to the lowest part of the room. 
The patient is usually placed on an operating table 
some three feet above the floor, so there is a two-foot 
margin of safety above the patient to allow for air tur- 
bulence, which may spread the anesthetic mixture. 

Areas in the operating suite, such as corridors, steri- 
lizing rooms, scrub rooms, and X-ray control rooms, are 
not considered hazardous if they are separated from 
operating rooms or flammable anesthetizing locations 
by a door that can be closed. Operating suites should be 
ventilated in accordance with the National Electrical 



Code. Ventilation may dilute the explosive agent 
enough so that it is no longer flammable. Anesthetic 
recovery rooms are not considered hazardous locations 
unless they are used specifically for induction of 
inhalation anesthesia with flammable agents. 

According to NFPA 56A, storage spaces must be 
ventilated by gravity or by mechanical means at a rate 
of not less than eight air changes per hour. The fresh 
air inlet must be located near the ceiling and the ex- 
haust located three inches above the floor. Since most 
flammable agents are heavier than air, the flammable 
gas will sink to floor level, where it will be sucked out 
through the exhaust vent. NFPA 56A also directs that 
exhaust air must be discharged to the outside of the 
building, at least 12 feet above ground, to prevent its 
reentry into the building. If exhaust fans are used, they 
must have nonsparking blades and the fan motor must 
be connected to the emergency electrical system. All 
electrical installation within the storage area must be 
explosion-proof; specifications for explosion-proof elec- 
trical equipment are in the National Electrical Code 
(NFPA 70) in the section on hazardous locations, Class 
1 , Group C, Division 2 type equipment. 

Piping flammable anesthetic gases is prohibited, be- 
cause if there is a leak in the piping system, any area of 
the hospital can develop an explosive atmosphere. 

Controlling ignition sources: Open flames and smok- 
ing are prohibited in flammable locations. Elimination 
of electrostatic charges is accomplished by providing 
routes for these charges to dissipate, thereby prevent- 
ing charges from building up. Humidity is used in 
operating rooms because it provides a moist film on 
nonconductive surfaces to bleed off any electrostatic 
charge. Flammable anesthetizing locations must have a 
relative humidity of not less than 50% at a temperature 
of 70°F, plus or minus 5°F. 

Conductive flooring equalizes electrostatic charges 
on personnel and equipment in the operating room. 
This flooring is installed in hazardous locations and ex- 
tends at least 10 feet outside the door of the flammable 
anesthetizing location to bleed off any electrostatic 



12 



U.S. Navy Medicine 



charge from a person's body before that person enters 
the room. The floor's average resistance must be 
between 25,000 and 1 million ohms; NFPA 56A de- 
scribes the test for measuring this resistance. Resist- 
ance must be measured at least once a month, and a 
permanent record must be kept of the readings. 

Accessories such as operating table covers, stretcher 
pads, pillows, and cushions must be made from conduc- 
tive material. Items required for anesthesia or surgery 
must also be conductive, including re-breathing bags, 
head straps, and face masks, as well as operating room 
furniture. Conductive shoes or shoe coverings must be 
used, and must have a resistance value under 500,000 
ohms. Silk, woolens, synthetic materials, cotton, rayon, 
and nonwoven materials are not permitted in the 
hazardous area as they may generate an electrostatic 
spark. 

Control of electrical equipment that may generate 
arcs and sparks is another important element in safety 
strategy. An isolated electrical system, with explosion- 
proof receptacles and attachment plugs, is required. 

Ceiling-suspended fixtures, such as the operating 
room light, shall not suspend into the hazardous area 
below the 5-foot level in the operating room. If the fix- 
ture is enclosed, the enclosure cannot enter the hazard- 
ous area unless it is approved for use in hazardous 
locations. Fixtures located above the hazardous location 
must be installed so that, whatever the fixture's posi- 
tion, no sliding contacts or arcing or sparking parts 
extend into the hazardous location. X-ray tube heads 
and tables and X-ray equipment installed permanently 
in flammable anesthetizing locations must be approved 
for hazardous locations. The exceptions are: 

• Equipment designed to operate on eight volts or less. 

• Portable electrical or electronic equipment mounted 
in an enclosure and protected by an approved positive 
pressure ventilation system. Enclosures must be sup- 
plied with air from a nonhazardous location. The air 
must be circulated to maintain, within the enclosure, a 
positive pressure of at least one inch of water above the 
pressure of the hazardous area's atmosphere. The en- 
closure must have a means (such as an interlock) to 
shut off the electricity if room temperature exceeds 
60°C or 150°F, or if the pressure falls. 

• Equipment mounted on a stable stand which elevates 
the primary electric or electronic portion of the unit at 
least five feet above the floor. 

• Equipment that is intrinsically safe because it is in- 
capable of releasing sufficient electricity to ignite in- 
flammable anesthetic mixtures. 

Another source of ignition is the electrosurgical unit, 
which provides a high-frequency spark. NFPA 56A 
prohibits the use of electrosurgical units in the area of 
the head, neck, and oropharynx while flammable anes- 
thetizing agents are being administered. The decision 
to use flammable agents during electrosurgery in other 
parts of the body should be based on good medical 
reasons. If flammable agents are administered during 



electrosurgery, the patient should be draped to provide 
a barrier that will prevent flammable mixtures from 
escaping into the area where the electrosurgical equip- 
ment is being used. 

NFPA 56A addresses the use of window-type tem- 
perature-regulating units or air conditioning units. 
There should be a vertical divider in each unit, so the 
atmosphere in the room cannot come in contact with the 
unit's compressor or motor. 

NONFLAMMABLE LOCATIONS 

Requirements for nonflammable anesthetizing loca- 
tions are described in the section of NFPA 56A dealing 
with all anesthetizing locations (see US Navy Medicine, 
June 1977). Nonflammable anesthetizing locations shall 
have a sign prominently posted at all entrances to 
inform personnel that flammable anesthetizing agents 
are not to be used in the area. The flooring in non- 
flammable anesthetizing locations need not be conduc- 
tive. 

MIXED FACILITIES 

If an operating or delivery suite contains both flam- 
mable and nonflammable anesthetizing locations, it is 
considered a mixed facility. In mixed facilities, each 
anesthetizing location must be labeled to indicate 
whether flammable agents are used there, or whether 
the location is to be used only for nonflammable 
anesthetics. Conductive flooring is required only in the 
flammable anesthetizing locations. All equipment, 
including portable X-ray equipment and furniture, in- 
tended for use in both flammable and nonflammable 
anesthetizing locations shall meet requirements for 
flammable locations. 

The requirements for mixed facilities are essentially 
the same as requirements for flammable anesthetizing 
locations. 

SUMMARY 

If a facility has only flammable anesthetizing loca- 
tions, the flammable locations must meet general re- 
quirements for all anesthetizing locations (described in 
US Navy Medicine, June 1977) as well as the specific 
requirements outlined above for flammable locations. 

If a facility has only nonflammable anesthetizing 
locations, then only the general requirements for all 
anesthetizing locations need be met, and the locations 
shall be labeled nonflammable. 

If a facility has both flammable and nonflammable 
anesthetizing locations, each room shall meet appropri- 
ate requirements depending on whether it is used for 
flammable or nonflammable anesthetics. But all equip- 
ment, including furniture and electrical equipment, 
must meet requirements for flammable anesthetizing 
locations. 



Volume 68, July 1977 



13 



Fees for Records 

As prescribed in the NAVCOMPT Manual, para- 
graph 035887, Navy medical facilities must collect the 
following fees for providing copies of medical records to 
the public: 



Fee 
$8 per hour 



Service 

Searching for and 
processing records 

Typing $2 per page 

Reproducing records $.05 per copy 

Lending X-rays $1.50 per X-ray 



Copying X-rays 



$1.50 per 8" x 10" copy 
$2 per 10" x 12" copy 
$3 per 14" x 17" copy 



The minimum charge for providing copies of a medi- 
cal record is $5. The requester normally must pay fees 
in advance, unless the request is so urgent that a delay 
to wait for payment would adversely affect the re- 
quester. 



Instructions and Directives 

Guidelines for inpatient administration 

Naval medical centers and hospitals should improve 
inpatient administrative procedures to ensure that 
active-duty inpatients return to duty as soon as they are 
medically fit. Inpatients should be discharged as soon 
as the physician dictates the narrative summary, with- 
out having to wait until the summary is transcribed and 
signed. (A suggested short discharge form is an enclo- 
sure to this instruction.) Patient affairs officers should 
follow up to make sure that narrative summaries reach 
the command and are placed in the health record after 
the patient is discharged. 

Navy medical facilities should discharge active-duty 
patients whenever possible, instead of keeping them on 
the sick list. If a patient cannot be discharged to full 
duty, there are several alternatives: 

• Discharge with continued treatment as an outpatient. 

• Discharge with convalescent leave granted as "delay 
in reporting." 

• Discharge to a medical holding company, for 
active-duty enlisted inpatients. A medical holding 
company is a special unit set up for convalescing pa- 
tients who do not require inpatient care but are not yet 
ready for full duty. 

• Discharge of active-duty officers to their command 
or, if this is not possible, to the commandant of their 



naval district or a type commander while they recu- 
perate and await full or limited duty orders. 

Patients shall be discharged when medically indi- 
cated, without prior administrative scheduling on a 
duty party list. Naval medical facilities shall maintain 
the capability to discharge patients any time between 
0800 and 2400, seven days a week, by staggering work 
hours or maintaining a specially trained watch. 

As part of their utilization review program, naval 
hospitals and medical centers shall review policies on 
authorizing absence status for active-duty inpatients. 
Absence statuses include convalescent leave, annual 
leave, and authorization to subsist at home. As attend- 
ing physicians submit recommendations to place inpa- 
tients in one of these statuses, the director of clinical 
services shall suggest a discharge alternative when 
appropriate. Convalescent leave for active-duty inpa- 
tients should be authorized only for patients who will 
require continued hospitalization on their return. In 
most cases, convalescent leave shall be granted con- 
current with inpatient disposition as delay in reporting 
to the patient's command. Annual leave shall be 
granted to inpatients only in emergencies, and liberty 
authorized only in unusual circumstances or when the 
physician determines that liberty is a necessary part of 
treatment.— BUMED Instruction 6320.55 of 4 Feb 
1977. 

'A' and 'C school grade transcripts 

When hospital corpsmen graduate from "A" or "C" 
school, the training activity shall enter a transcript of 
their grades on NAVPERS 1070/613 (Administrative 
Remarks) and forward a copy to BUMED Code 34. 
Transcripts of courses completed after 1 Jan 1977 shall 
be placed permanently in the member's official service 
record. Transcripts of courses completed before 1 Jan 
1977 are retained by BUMED until the member is 
separated from active duty, and are then sent to the 
National Personnel Records Center in St. Louis. — BU- 
MED Notice 1510 of 9 Feb 1977. 

Reporting procurement of nonstandard 
medical and dental materiel 

Commands covered by this instruction must submit 
monthly reports of purchases of consumable medical 
and dental items by the 20th of the following month to 
the Naval Medical Materiel Command, 3500 S. Broad 
St., Philadelphia, Pa. 19145. Items are to be reported 
by National Stock Number, National Drug Code num- 
ber, or Federal Supply Code manufacturer number plus 
manufacturer's catalog number. 

Commands are to report on keypunched data cards, 
following punching and coding directions given in this 
instruction. Activities which do not have automated 
data processing capability may submit typed data on 
form NAVMED 6700/2.— BUMED Instruction 6700.20L 
of 31 March 1977. 



14 



U.S. Navy Medicine 



Submitting Medical Board data 

The first carbon copy of NAVMED 6100/1 (Medical 
Board Report Cover Sheet) must be submitted to the 
Naval Medical Regional Data Center for all patients 
who appear before a Medical Board, including patients 
referred to the Central Physical Evaluation Board. This 
requirement will be reflected in Change 90 to the 
Manual of the Medical Department. — BUMED Instruc- 
tion 6100.5, change transmittal 2 of 1 April 1977. 

Reporting inpatient workload and morbidity 

These changes have been made in requirements for 
reporting inpatient workload and morbidity data: 

• Reporting facility location codes will no longer be re- 
ported. 

• The military theater of operations will no longer be 
reported. 

• Professional services codes have been added for 
"vascular surgery" and "vascular surgery, pediatric." 

• Activities must now identify active-duty enlisted pa- 
tients who are discharged to a medical holding 
company. 

• Activities must report data on military patients dis- 
charged with convalescent leave, giving the number of 
days of leave recommended or granted. — BUMED In- 
struction 6300.3, change transmittal 5 of 6 April 1977. 

Requesting follow-up clinical information 

When a patient is transferred or referred from a Navy 
health care facility to another military health care facil- 
ity, the attending physician or dentist can ask for fol- 
low-up clinical information by sending DD Form 183 to 
the receiving hospital or attaching this form to the pa- 
tient's clinical or health record. Patient affairs officers 
or medical/dental administrative officers should keep a 
list of each patient for whom follow-up information was 
requested, with the place to which the patient was 
transferred and the date of the transfer. If follow-up in- 
formation is not received, the requesting facility should 
send a second request and, if that fails, seek help from 
BUMED Code 7. 

Patient affairs officers at Navy medical centers and 
hospitals shall record names of inpatients referred by 
Medical Department representatives at other facilities. 
A copy of the narrative summary (SF 502) shall be sent 
to the referring physician or dentist within seven days 
after the patient's discharge. The director of clinical 
services is responsible for establishing a system to 
ensure timely and comprehensive responses to all 
requests for clinical follow-up information. — BUMED 
Instruction 6150. 32A of 6 April 1977. 

Medical holding companies 

Each naval regional medical center, hospital, drug 
rehabilitation center and alcohol rehabilitation center is 
authorized to establish one medical holding company. 



At naval activities other than regional medical centers 
and hospitals, the commanding officer shall: 

• operate the medical holding company as part of the 
command. 

• use medical holding company personnel to perform 
duties commensurate with their physical limitations. 

• ensure that names of personnel in the medical hold- 
ing company are properly recorded on the Manpower 
Management Information System report. 

• designate a liaison officer or an officer in charge to 
run the medical holding company. 

Commanding officers at regional medical centers and 
hospitals shall transfer eligible patients, with their 
records and accounts, from the inpatient facility to the 
medical holding company for temporary duty as outpa- 
tients, or for temporary additional duty if the person 
originally received temporary additional duty orders to 
enter the hospital. Patients assigned permanently to 
shore duty near the medical facility shall be discharged 
to the parent activity instead of to the medical holding 
company. When non-Navy enlisted patients are placed 
in the medical holding company, administrative pro- 
cedures shall be coordinated with local units of the pa- 
tient's service. 

The CO shall also establish cross referenced records 
in the hospital and medical holding company to ensure 
that personnel in a medical hold status are evaluated 
at least once a week and do not remain in the company 
longer than 60 days, including any convalescent leave. 
If the total convalescent period is expected to exceed 60 
days, a medical board disposition shall be pursued. 

On admission to the medical holding company, 
active-duty patients shall bring a copy of their inpatient 
admission/disposition record (NAVMED 6300/5). The 
medical holding company maintains this form until the 
patient is discharged, when the form is completed and 
forwarded to the appropriate activity for automated 
data processing.— BUMED Instruction 1306. 72C of 7 
April 1977. 

Reporting interment expenses 

Naval districts no longer need to submit quarterly re- 
ports on funeral and burial expenses paid to families of 
deceased Navy members. The report, Interment Allow- 
ance Review Data (MED 5360-10), will now be sub- 
mitted annually, by 30 October, to BUMED (Code 734). 
—BUMED Instruction 5360.21B of 21 April 1977. 

Disease alert reports 

This instruction includes a revised list of communica- 
ble diseases on which Medical Department personnel 
should submit disease alert reports. The following diag- 
noses are new to the list: hepatitis A (infectious hepati- 
tis), hepatitis B (serum hepatitis), Lassa fever, and 
Marburg virus disease. 

Names of certain diseases have been revised in line 
with currently accepted nomenclature: Phlebotomus 



Volume 68, July 1977 



15 



fever is now called sandfly fever, African tick-borne 
fever is called boutonneuse fever, amebic dysentery or 
abscess is called amebiasis, and bacillary dysentery is 
called shigellosis. The description "arthropod-borne" 
has been added to viral encephalitis and hemorrhagic 
fevers. 

Gonorrhea resistant to penicillin or to other drugs has 
been added to the list of infectious diseases which must 
be reported if numbers of patients exceed numbers 
normally expected for the area. 

If a crewmember on a Navy ship contracts a com- 
municable disease, a copy of the disease alert report 
should be sent to the medical officer of the appropriate 
fleet commander-in-chief, in addition to other address- 
ees. 

Specimens of cultures and acute and convalescent 
sera from patients with meningococcal meningitis shall 
be sent to the Neisseria Repository, Naval Biomedical 
Research Laboratory, Building 844, Naval Supply 
Center, Oakland, Calif, 94625.— BUMED Instruction 
6220.3B of 22 April 1977. 

Preventive Dentistry Program 

Under the Navy's new Preventive Dentistry Pro- 
gram, all active-duty Navy and Marine Corps members 
shall receive: 

• an annual oral examination. 

• a self-applied or professionally applied stannous 
fluoride prophylaxis, in conjunction with a stannous 
fluoride treatment, once a year and before the member 
deploys or is transferred to an area where dental 
support is limited. 

• an annual periodontal disease index examination. 

• oral health instruction given individually or in group 
sessions. 

Fluoride content of water supplies at Navy installa- 
tions shall be adjusted in line with OPNAV Instruction 
1130.1. 

Each month, commanding officers of Navy and 
Marine Corps activities shall give the dental facility re- 
sponsible for care of command members a list of per- 
sonnel to be examined that month. Commanding offi- 
cers shall also tell their personnel where to report for 
the dental exam. Personnel may be assigned for exami- 
nation in any month from January through October. 

A preventive dentistry program may be established 
for dependents, in line with Defense Department 
guidelines for dependent dental care at military facili- 
ties. Under DOD policy, routine dental care is author- 
ized for dependents outside the U.S., and in designated 
areas in the U.S. where adequate civilian dental care is 
not available. Routine dental care includes general 
operative, surgical, and prosthodontic treatment, and 
other care furnished to active-duty military members. 
Emergency, adjunctive and preventive dental care is 
still authorized by law for all military dependents. — 
SECNAV Instruction 6600. IB of 2 May 1977. 



Radiation physical examinations 

A routine chest roentgenogram is no longer required 
as part of a radiation physical examination, but may be 
performed if clinically indicated. — BUMED Notice 6470 
of 19 May 1977. 

FY78 residency /fellowship training program 

Accredited residency training programs are con- 
ducted at eight naval medical training hospitals in 30 
specialties and subspecialties (see chart). A limited 
number of positions are available for Medical Corps 
officers to train at civilian institutions in specialties and 
subspecialties for which there is no inservice training 
program and for which there is a clearly defined Medi- 
cal Department requirement. 

Applications for training should be submitted by 15 
Aug 1977 to the Commanding Officer, Naval Health 
Sciences Education and Training Command {Code 4), 
National Naval Medical Center, Bethesda, Md. 20014. 
BUMED Instruction 1520. 10G of 12 May 1976 gives 
details on preparing applications. Applicants will be 
notified of the results in October 1977.— BUMED 
Notice 1520 of 26 April 1977. 

RESIDENCIES/FELLOWSHIPS IN NAVAL ACTIVITIES INDICATING POSITIONS 
AT EACH YEAR LEVEL BY ACTIVITY 





H 
B 

M 
4J 

o "0 
$ 

m u 
M <u 

G ^ 
> O 


> 
-a 

D 

r: 
OJ 

o d 


M -H 

5> ^ 

H -i 

3 


0) 
+J 




a 

rH 

e c 

it. a 

U ft 


O 
V 

0! 

H 
U 

.a 

'-i 


01 
H 

-H 
> 

a 

o 
vn 

X 
Q 

a 


c 
m 
■-I 
M 
id 
O 


■-i 
o 
u 
m 
<n 


+j 



a 

: 

u 


c 


O 
■H 

o 

in 


U 


4J 
O 


Aerospace Medicine ** 


J 


b 












b 








Anesthesiology ** 


2 


is 


4 








4 




4 


6 




Derma tolaqy ** 


3 


6 


I 














4 




Family Practice 


3 


33 




it 


1 


y 




« 








Hand Surqerv 


i 


i 
















1 




Internal Medicine ** 
and Subspecialties 


3 


30 


6 








4 




8 


12* 




Cardiovascular Disease 


2 


4 


2 














2 




Endocrinology s 
Metabolism 


2 


1 


1 


















Gas troenterolagy 


2 


2 


1 














i 




Heiriatology/Oncology 


2 


i 


1 














2 






2 


1 
















1 






7. 


4 


1 












1 


2 






:. 


3 


3 


















Neurosurgery ** 


4 


1 


1 


















Nuclear Medicine 


2 


2 


2 


















Obstetrics & Gynecology 


4 


16 


2 








3 




b 


4 




Occupational Medicine 


J 


1 


















1 




3 


H 


J 








2 






J 




Orthopedic Surgery ** 


4 


12 


2 








3 




3 


4 






4 


i< 


2 








6 






J 






4 


1 


3 








2 




2 


i 




Pediatrics 


3 


16 


3 








3 




b 


b 




plastic Surqery 


2 


i 














1 




1 


Preventive Medicine ** 


3 


1 




















3 


1 I 


4 








3 




4 






Radiology ** 


:< 


14 


4 








3 






1 




Surgery ** 


4 


12 


2 








2 




4 


4 




Peripheral Vascular Surgery 


1 


1 
















1 




Thoracic & CV Surgery 


2 


2 


i 














1 




urology 


4 


6 


1 








1 




1 


2 




TOTALS ; 




236 


52 


9 


9 


9 


33 


14 


40 


68 


2 



* This is a three year program. 
** Indicates numbers of years training beyond GME year one. 



16 



U.S. Navy Medicine 



Education & Trainin 



a 



Understanding Goes A Long Way 



LT Gary J. Spinks, MSC, USN 

LT Hiram H. Belding IV, MSC, USNR 



In any health care facility, there is 
likely to be at least an occasional in- 
cident or complaint which results 
from a patient's unsatisfactory con- 
tact with a staff member. If a staff 
member is discourteous or does not 
answer a patient's questions, the 
patient may get the impression that 
all the hospital's employees are in- 
sensitive to his emotional needs. He 
may then complain about the care 
he has received, even if the treat- 
ment of his medical condition was 
excellent. 

To encourage courtesy toward 
patients, CAPT E.B. McMahon 
(MC), commanding officer of Naval 
Regional Medical Center Charles- 
ton, S.C., started a patient relations 
training program for staff members 
working in patient contact areas — 
including watch standers, security 
guards, corpsmen in branch clinics, 
and admission and information desk 
receptionists. 

To be fully effective in caring for 
patients, staff members must con- 
sider the patient's family, ethnic 
and religious background as well as 
medical condition. So people who 
work in areas where the patient first 
"meets" the hospital learn about 
the social and environmental in- 
fluences which shape a patient's 
behavior, and receive continuing 
education in patient-staff relations. 

Previously, there were two such 
training programs in our command. 
Our general practice clinic con- 

LT Spinks was administrative assistant to 
the director of administrative services, and is 
now assistant chief of the Patient Affairs 
Office, at Naval Regional Medical Center 
Charleston, S.C. 29408. LT Belding (Ph.D.) 
is a psychologist on the staff of NRMC 
Charleston. 



ducted a patient relations program 
taught by personnel from the local 
counseling and assistance center. 
The aim of this program — a loosely 
structured series of six seminars on 
human communications — was to re- 
duce the number of patient com- 
plaints by teaching staff members 
the dynamics of interpersonal com- 
munication. Instructors used role 
playing techniques to teach listen- 
ing skills. 



which students act out typical 
patient-staff encounters, 

THE CHARLESTON PROGRAM 

Our region-wide Patient Rela- 
tions Program got under way in 
May 1976, with the goal of making 
staff members aware of the patient 
on a human level, as well as the 
professional level. We plan to send 
as many members of the staff as 




Staff member politely answers patient's 

The other program, at the Naval 
Station branch clinic, took a differ- 
ent approach: students studied the 
Navy Customer Service Manual, 
and were required to master this 
material to qualify for advance- 
ment. 

While these programs resulted in 
better patient relations, the courses 
were limited to a small group of re- 
gional personnel. We needed one 
general approach that would involve 
as many staff members as possible. 
We came up with a unique program 
that combines textbook lessons with 
films, videotapes, and sessions in 






questions about prescription drugs 

possible through the program, and 
to ensure that the training runs con- 
tinuously. Because there are not 
enough outside instructors for the 
large number of people who need 
the training, we designed a pro- 
gram which relies on our com- 
mand's own resources. 

We decided to use a socio-drama 
method of instruction. The socio- 
drama consists of several exercises 
in group role playing, after which 
students act out typical conflict- 
laden encounters between staff 
members and patients. This role 
playing is designed to make stu- 



Volume68, July 1977 



17 



dents think about the possible 
effects of their behavior before they 
talk to a patient. We show movies 
and videotapes to illustrate the 
principles stressed in the socio- 
drama. 

Each student gets a copy of the 
revised Navy Customer Service 
Manual (NAVPERS 10119). Written 
in a simple, readable style, the 
manual has illustrations and exam- 
ples of interpersonal problems that 
may arise in a military environment. 
The four chapters are discussed 
separately during training sessions, 
and movies are shown to reinforce 
the material. 

Here is the outline of our pro- 
gram: 

Session 1. Half of students par- 
ticipate in socio-drama (accommo- 
dates 70 people) and view movie, 
"You in OPD [Outpatient Depart- 
ment]" (MN- 10646). (ZVi to 3 
hours) 

Session 2. One week later, re- 
maining 50% of personnel partici- 
pate in socio-drama and view movie. 
(2'/2 to 3 hours) 

Session 3. One month later, stu- 
dents read Chapter 1, "Face-to- 
Face," in manual, and view video- 
tape, "Interpersonal Communica- 
tions" (H-A-PMB-917), (1 hour) 

Session 4. One month later, stu- 
dents read Chapter 2, "Navy Cus- 
tomers and Their Needs," and view 
videotape, "Motivation Through 
Identification of Crisis" (H-A-PMB- 
919). (1 hour) 

Session 5. One month later, stu- 
dents read Chapter 3, "Manning 
the Contact Point," and see video- 
tape, "A System for Understanding 
Human Behavior, Part 1" (NN-30- 
71 No. 7131). (1 hour) 

Session 6. One month later, stu- 
dents read Chapter 4, "The Team," 
and view Part 2 of "A System for 
Understanding Human Behavior" 
(NN-47-71 No. 7137). (1 hour) 

Session 7. Examination is given. 
A second socio-drama is conducted 
to reinforce the principles and to in- 
struct new staff members. (3 hours) 

Session 7, which ends the pro- 
gram, also begins the next set of 
seven meetings. The whole pro- 



gram is given twice a year. 

The appeal of this format is its 
simplicity and the fact that it re- 
quires no assistance from other 
organizations. Its aim is to inspire 
the individual to set and reach self- 
formulated goals. When staff mem- 
bers show through their behavior 
that they have learned the princi- 
ples of good patient relations, this 



accomplishment is noted in their 
performance evaluations. 

To test the program's effective- 
ness, we monitored our patients' 
complaints about staff members. 
After the second training session 
there was a dramatic reduction in 
the number of such grievances. 
Today, complaints about staff mem- 
bers' discourtesy are rare. 



BUMED SITREP 



NEW RESERVE BILLETS ... The Sur- 
geon General has named six inactive 
Reserve flag officers to new nationwide 
functional billets, where they will par- 
ticipate directly in management of the 
Navy's Medical Reserve. Until now, 
these officers were active only at the 
Surgeon General's request, on an ad 
hoc basis. 
The new billets and appointees are: 

• Reserve Inspector General, Medical 
(Code 00-R): RADM David B. Carmi- 
chael, MC, USNR-R 

• Director of Medical Reserve Educa- 
tion and Training (Code 01-R): RADM 
Winston H. Weese, MC, USNR-R 

• Director of Operational Medical Sup- 
port (Code 3-R): RADM William J. 
Mills, MC, USNR-R 

• Director for Medical Reserve Support 
(Code 4-R): RADM Victor P. Bond, MC. 
USNR-R 

• Director for Aerospace Medicine 
(Code 5-R): RADM Harold M. Voth, 
MC, USNR-R 

• Director for Medical Reserve 
Recruiting, Career Development 
and Communications (Code 6-R): 
RADM Matthias H. Backer, Jr., MC, 
USNR-R 

In another Reserve development, a 
Medical Reserve Policy Board has been 
formed to deal with current concerns of 
medical Reservists. 

WORD PROCESSING . . . National 
Naval Medical Center and NRMC Ports- 
mouth, Va., are implementing COMPU- 
TEXT word processing systems. 
COMPU-TEXT, a mini-computer based 
system with text editing capability, is 
expected to improve the quality and ef- 
ficiency of medical transcription and 
decrease transcription costs at the two 
facilities. NRMC San Diego, the first 
U.S. hospital to install COMPU-TEXT, 
eliminated a backlog of untranscribed 



reports, and achieved a turnaround time 
of less than 72 hours for all dictated 
material, after using the system for 
three months. 

BUMED 's Health Care Administra- 
tion Division is planning to install a 
centralized word processing system at 
BUMED. 

UNIFORM ACCOUNTING ... At the 

direction of the Defense Department, 
Navy, Army, and Air Force representa- 
tives are working on a standard account- 
ing system for the three military 
medical services. Currently, cost and 
performance data from Army, Navy and 
Air Force medical facilities cannot be 
compared because the reports are 
prepared in different formats. 

A tri-service task force, working in 
the Office of the Assistant Secretary of 
Defense for Health Affairs, will develop 
a standard chart of cost accounts. The 
chart will enable military medical ser- 
vices to allocate funds uniformly, and 
will make it easier to compare military 
medical facility cost data with similar 
data from civilian hospitals. 

REGENT ADVISER NAMED . . . CAPT 
Eugene M. Bryant (MSC) has been ap- 
pointed Navy regent adviser to the 
American College of Hospital Adminis- 
trators' regent-at-large for uniformed 
service members. He will function as 
the liaison between the College and its 
Navy affiliates. 

Membership in the American College 
of Hospital Administrators is open to 
administrative officers in hospitals and 
other health care programs. For infor- 
mation contact CAPT E.M. Bryant, 
MSC, USN, Commanding Officer, Naval 
School of Health Care Administration, 
National Naval Medical Center, Bethes- 
da, Md. 20014, (Area code 202) 295- 
1204, Autovon 295-1204. 



18 



U.S. Navy Medicine 



Back When 



Hospital Apprentice Robert H. Stanley: 

Hero Lost in History 



ENS Francis C. Brown, MSC, USN 

The Medal of Honor is the high- 
est award for bravery that a U.S. 
citizen can earn. Although the 
Medal is awarded in the name of 
Congress, the actual presentation of 
this coveted decoration is made by 
the President or by an official he 
appoints. 

Hospital Apprentice Robert H. 
Stanley, USN, was the first hospital 
corpsman to earn the Medal of 
Honor. Several researchers have 
tried to track down information on 
Stanley, but little is known about 
the life of this early Hospital Corps 
hero. 

We do know that he was born in 
Brooklyn, N.Y., on 2 May 1881. 
After enlisting in the Navy on 28 
March 1898, Stanley was assigned 
to serve on the USRS Vermont. 

Almost two years later, in June 
1900, the Boxer rebellion erupted in 
China and the foreign legations in 
Peking were beseiged. HA Stanley, 
then serving in the area, went with 
the first detachment of U.S. Ma- 
rines to guard the legation quarter 
during the 56 days of the seige. The 
travails of that legation guard are 
described in this excerpt from the 
Annual Report of the Surgeon 
General, U.S. Navy, 1901 (p 271): 

The Marine Guard in Pekin was prac- 
tically beseiged, under almost constant 
Fire, from about the middle of June until 
August 14. During this period they were 
not only subject to the usual hazards of 
war, but suffered the hardships due to 




ENS Brown is a member of the staff of 
Naval Regional Medical Center Philadelphia, 
Pa. 19145. He thanks John E. Lelle, secre- 
tary of the Orders and Medals Society of 
America, for assistance in preparing this 
article. 



insanitary surroundings in a confined 
space, without suitable food or adequate 
facilities for the sick and wounded 
owing to the overcrowding. Of the total 
force of 56 officers and enlisted men, 7 
were killed outright and 10 were 
wounded, 1 of the latter dying subse- 
quently as a result of the wound and an 
intercurrent attack of typhoid fever. 

According to one account (1), at 
one point the American legation had 
to get a message through to the 
English legation. Because the route 
to be traversed went through a 
quarter packed with rebels and the 
risk was great, the American minis- 
ter, Mr. Conger, said he could not 
order anyone to go. When Conger 
asked for volunteers, HA Stanley 
immediately stepped forward. We 
know that Stanley completed his 



Early Medal of Honor 

important mission, but can only 
guess at the difficulties he en- 
countered in running the Boxer 
gauntlet. 

The Medal of Honor was pre- 
sented to HA Stanley aboard the 
USS Brooklyn, in the presence of 
the entire crew, in 1902. The rest of 
Stanley's naval career is lost to his- 
tory. He retired from the Navy on 1 
Feb 1939 and died on 15 July 1942. 

His citation, dated 19 July 1901, 
reads: "For distinguished conduct 
in the presence of the enemy in 
volunteering and carrying messages 
under fire at Peking, China, July 12, 
1900." 

REFERENCE 

1. Mulholland, St. Clair A: Military 
Orders-Congress Medal of Honor Legion of 
the U.S. Philadelphia: Town Printing Co 
1905. 




Marines defend Peking Legations during Boxer rebellion. Painting by John Clymer 



Volume 68, July 1977 



19 



Clinical Notes 



Prepackaging Topical Ointments and Creams 



LCDR Larry L. Karch, MSC, USN 

In the Pharmacy Service of Naval 
Regional Medical Center Charles- 
ton, S.C., yearly increases in work- 
load have placed growing demands 
on all sections of the Service, par- 
ticularly the compounding and pre- 
packaging section. Topical prepara- 
tions account for much of this 
section's workload. Staff members 
used to spend a considerable 
amount of time prepackaging topi- 
cal ointments and creams into the 
various size jars required when one 
uses the traditional spatula method. 

To save time, we developed a 
more efficient method of prepack- 
aging topical ointments and creams. 

METHOD 

After a topical ointment or cream 
has been compounded, it is placed 
in a section of plastic tubing. The 
best tubing to use is 6 inches wide 
and 0.005 inches thick, and comes 
in rolls of 950 feet (NSN 8135-00- 
890-1843). A suitable length of 
tubing is heat-sealed across one end 
with a thermal impulse sealer 
(Figure 1), so that the tubing is 
converted into a bag. The open end 
of the bag is brought up through a 
metal ring attached to a ringstand, 
and spread out over another metal 
ring from which the ringstand 
extension has been removed (Figure 
2). The top ring, with the plastic bag 
spread over it, is dropped down on 
the ring attached to the ringstand 
(Figure 3). A large, institutional- 
type kitchen spoon is then used to 
fill the bag with topical ointment or 

LCDR Karch is chief of the Pharmacy Ser- 
vice, Naval Regional Medical Center, New- 
port, R.I. 02840. When he wrote this article, 
he was chief of the Pharmacy Service at 
Naval Regional Medical Center Charleston, 
S.C. 




FIGURE 1. One end of tubing is heat- 
sealed in thermal impulse sealer. 

cream. After the bag is filled, it is 
removed from the rings and ring- 
stand, and the top is heat-sealed 
with the thermal impulse sealer 
(Figure 4). Excess plastic is trim- 
med from the top, and the bag, 
properly labeled, is stored until 
needed (Figure 5). 

To prepackage the contents of the 
bag, a corner is cut away with 
scissors (Figure 6) and the bag is 
held over the jars to be filled. As the 
bag is squeezed at the top, its con- 
tents drop into the jars (Figure 7). 
Not counting the time required to 
remove and replace jar lids, a dozen 
two-ounce ointment jars can be 
filled this way in less than one 
minute; the exact filling time de- 
pends on the consistency of the oint- 
ment or cream. After the jars are 
labeled, they are ready to be dis- 
pensed. 

When compounding is not re- 
quired, the contents of large stock 
containers can be transferred to a 
plastic bag and then prepackaged in 
the same way. 



FIGURE 2. Open end of bag is drawn 
through two rings. 




FIGURE 3. Top ring is dropped on 
lower ring to hold bag for filling. 



20 



U.S. Navy Medicine 



f 




FIGURE 4. Bag is heat-sealed in thermal impulse sealer. 




FIGURE 5. Labeled bag is ready for storage. 




FIGURE 6. To transfer contents into jars, bag is cut at one 
corner. 




FIGURE 7. Contents are squeezed into ointment jars. 

Volume 68, July 1977 



Preventive Medicine 



The Right Way to 
Thaw Meat 



Correct storage and handling of food is the key 
to preventing food-borne illness. Frozen foods 
must be thawed carefully because freezing tends 
to break down tissue cells, making the food much 
more susceptible to bacterial invasion after 
thawing. 

NAVMED P-5010, Manual of Naval Preventive 
Medicine, outlines procedures for thawing meat: 
frozen meats must be thawed gradually under 
refrigeration — the ideal temperature range for 
thawing is 36°F to 38°F — in their original wrap- 
pings or containers. This procedure must be used 
to thaw any meat, including beef, pork, fish, and 
poultry. 

An alternate method, outlined in NAVSUP 421, 
Food Service Operations, permits meat to be 
thawed at room temperature (70°F), provided the 
meat is thawed in its original wrapping or con- 
tainer. This alternate procedure was established 
primarily for small afloat units that do not have 
room for thaw boxes, and is not approved by 
BUMED as a blanket substitute for refrigerated 
thawing. 

Some older large ships also do not have thaw 
boxes. BUMED recommends that these ships use 
their chill boxes or reach-in refrigerators for 
thawing meat; when chill spaces are inadequate 
for thawing food, the meat preparation room may 
be used, provided the room is air conditioned and 
meat is thawed in its original unopened container. 
This method is not a permanent solution to lack of 
thaw spaces: ships with inadequate thawing 
facilities should be refitted with meat thawing 
boxes. 

These policies will be included in a forthcoming 
revision of Chapter 1 of the Manual of Naval 
Preventive Medicine. 

Here are some other important points to re- 
member in thawing meat: 

• Thawed meats should not be refrozen. 

• Meats must not be thawed by exposure to ex- 
cessive heat or by immersion in water. 

• Fans should not be used to speed thawing, be- 
cause rapidly moving air dehydrates the meat. 

• Meat should be used as soon as possible after 
thawing. 

—Adapted from Pacific Health Bulletin. January 1977. 



21 



Professional 



The Mediastinal Mass: A Continuing 
Challenge to the Thoracic Surgeon 



CDR J. A. Gibbons, MC, USN 

M.J. O'Sullivan, M.D. 

CAPT R.G. Fosburg, MC, USN (Ret.) 



Although the histological classification and ana- 
tomic incidence of mediastinal masses have been 
clarified over the last 30 years {1-12), surgical man- 
agement of patients with such masses may continue 
to present unique problems. In this paper, we review 
our 15-year clinical experience with surgery for 
mediastinal masses, and emphasize some continuing 
problems. 

From 1960 through April 1976, at Naval Regional 
Medical Center San Diego, Calif., 129 patients un- 
derwent surgical exploration for a mediastinal mass. 
Of these patients, 66 were on active military duty, 44 
were military dependents, and 19 were retired from 
the military or veterans of military service. Patients' 
ages ranged from one month to 75 years ; the average 
age was 30 years. Each year of the study, from 3 to 
15 patients underwent surgery. 

Burkell's anatomic definitions {13) were used in 
this study. We made a simple map of the mediasti- 
num and, following boundaries found on lateral 
chest X-rays, divided the chest into three areas: 

• the anterior mediastinum— the region superior to 
the anterior border of the heart and extending back 
to the posterior mediastinum. 

• the posterior mediastinum— the area posterior to 
the anterior border of the vertebrae. 

• the middle mediastinum— the remaining area, 
over which the heart shadow is projected. 



Dr. Gibbons is assistant chairman, Department of Cardiotho- 
rack Surgery, Naval Regional Medical Center, San Diego, Calif. 
92134. Dr. O'Sullivan, formerly a staff cardiothoracic surgeon at 
NRMC San Diego, is now in private practice at 210 S. Juniper St., 
Escondido, Calif. 92025. Dr. Fosburg, formerly chairman of the 
Department of Cardiothoracic Surgery at NRMC San Diego, is in 
private practice at 6279 Del Paso Ave., San Diego, Calif. 92120. 

This paper was delivered at the first Pan American Congress 
on Diseases of the Chest, Lima, Peru, 1 June 1976. 



22 



Table I lists the anatomic locations of the masses 
we studied. 

The masses were classified according to their 
tissue of origin (Tables II, m, and IV). Primary 
masses (originating in the mediastinum) and second- 
ary masses were included. 

All patients in the study presented with a medias- 
tinal mass, as diagnosed on a chest X-ray. Only one- 
third (44) of the patients had symptoms (Table V), 
with chest pain and cough the most common. Sixty 
percent of patients whose masses were diagnosed as 
malignant had symptoms. 

One hundred and forty-five preoperative studies 
were completed as part of the diagnostic evaluation. 
Since scalene node biopsy and mediastinoscopy did 
not provide diagnoses for any patients in this study, 
more definitive surgical procedures were undertaken 
(Table VI). Angiographic procedures were also used 
in preoperative assessment (Table VII). 

A lateral thoracotomy was chosen for the surgical 
approach in 92 patients. In 31 patients, a median 
sternotomy was performed. Cervical exploration 
provided adequate exposure for surgery in six pa- 
tients. 

The mass was excised in 89 patients, and a portion 
of the mass was removed for biopsy in 38 patients. In 
two patients, the bulk of the mass was removed but 
residual tumor was left on vital structures. Resec- 
tions for malignant masses included 19 excisions, 16 
biopsies, and two partial resections. 

There were no deaths related to surgery. Twenty- 
four patients had postoperative complications (Table 
VIII), all of which responded satisfactorily to ther- 
apy- 

With the exception of four patients, cobalt radia- 
tion was administered to patients with a diagnosed 
malignant mass. Of the four exceptions, two patients 

U.S. Navy Medicine 



TABLE I. Anatomic Location of Masses 



Mediastinum 








Area 


Benign 


Malignant 


Total 


Anterior 


38 


26 


64 


Middle 


25 


6 


31 


Posterior 


29 


5 


34 




Total 92 


37 


129 



TABLE II. General Classification of Masses 



Type of Mass 


Benign 


Malignant 


Total 


Neurogenic 


15 


1 


16 


Thymic 


12 


6 


18 


Teratoid 


3 


5 


8 


Lymphoma 





15 


15 


Lymph node 


18 


8 


26 


Mesenchymal 


4 


1 


5 


Cyst 


20 





20 


Aneurysm 


2 





2 


Thyroid 


7 





7 


Hernia 


6 





6 


Other 


5 


1 


6 


Total 


92 


37 


129 



TABLE m. Malignant Masses 



Type of Mass 
(No. of patients) 



Anterior Middle Posterior Total 



Neurogenic (1) 
neuroblastoma 

Thymic (6) 
malignant thymoma 

Teratoma (5) 
embryonal 
seminoma 

Lymphoma (15) 
Hodgkin's disease 
Hodgkin's thymus 
lymphosarcoma 

Lymph node (8) 
metastatic 

Mesenchymal (1) 
rhabdosarcoma 

Other (1) 
cancer of azygos lobe 



3 
1 

8 
3 

1 



1 

6 

4 
1 

11 
3 
1 

8 

1 

1 



TABLE IV. Benign Masses 



Type of Mass 
(No. of patients) 



Anterior Middle Posterior Total 



Neurogenic (15) 
neurilemoma 
neurofibroma 
ganglioneuroma 

Thymic (12) 



thymoma 
hyperplasia 


6 
6 






6 
6 


Teratoid (3) 
teratoma 
dermoid 


2 

1 






2 

1 


Lymph node (18) 

sarcoid 

histo-granuloma 

coccidioidal granuloma 

granuloma 
■ hyperplasia 

sclerosing mediastimtis 


2 

3 
2 
2 


4 
2 
1 
2 




i 

5 
2 

2 


Mesenchymal (4) 
lipoma 
desmoid 
leiomyoma 
mesenchymoma 


1 


1 
1 


1 


1 
1 

1 

1 


Cyst (20) 
bronchogenic 
enteric 
pericardial 


4 
1 


5 
2 


5 
3 


14 
4 
2 


Aneurysm (2) 


1 




1 


2 


Thyroid (7) 


7 






7 


Hernia (6) 
Morgagni's 
Bochdalek's 
paraesophageal 




2 
1 


3 


2 
3 
1 


Other (5) 
sequestration 
absence of pericardium 
carcinoid 




2 

1 
1 


1 


3 

i 
i 


Total 


38 


25 


29 


92 



Total 



26 



37 



Volume 68, July 1977 



23 



TABLE V. Symptoms 





Malignant Mass 


Benign Mass 






N = 37 


N = 92 


Total 


Chest pain 


10 


S 


18 


Cough 


6 


3 


9 


Dysphagia 


1 


3 


4 


Dyspnea 


1 


2 


3 


Fever 


1 


1 


2 


Arm edema 


1 


1 


2 


Weight loss 


1 


1 


2 


Myasthenia 




2 


2 


Vomiting 


1 




1 


Hemoptysis 




1 


1 


Total 


22 (60%) 


22 (24%) 


44(34%) 



TABLE VI. Diagnostic Evaluation 



Procedure 


Number 


Bronchoscopy 


28 


Angiography 


28 


Tomography 


22 


Scalene node biopsy 


15 


Esophagoscopy 


11 


Thyroid scan 


9 


Barium swallow 


8 


Mediastinoscopy 


7 


Echogram 


4 


Bone marrow 


3 


Lung scan 


3 


Gallium scan 


3 


Bronchogram 


2 


Lymphangiogram 


1 


Myelogram 


1 





Total 145 



TABLE VII. Angiographic 


Procedures 




Procedure 




Number 




Aortogram 

Pulmonary arteriogram 
Superior vena cavagram 
Complete heart catheterization 




15 
6 
4 
3 






Total 


28 





TABLE VDI. Postoperative Complications 



Complication 



Number 



Wound infection 

Pleural effusion 

Arrhythmia 

Pneumothorax 

Pneumohemothorax 

Pulmonary insufficiency 

Horner's syndrome 

Pulmonary embolism 

Empyema 

Pericardial effusion 

Chylothorax 

Gastrointestinal bleeding (stress) 



i 



Total 23* 



*18% of 129 patients seen in this study. 



TABLE DC. Deaths (N= 14) 



Tumor (No. of patients) 



Months from Surgery 



Anaplastic lymph node (7) 
Hodgkin's (3) 
Embryonal (3) 
Lymphosarcoma (1) 



4, 4, 4,4V!, 8, 8, 8 
4, 8 (suicide), 11 



24 



U.S. Navy Medicine 



with Hodgkin's disease refused therapy and, early in 
the study, one patient with malignant thymoma was 
not offered radiation therapy; one patient with rhab- 
domyosarcoma is being treated with pulsed chemo- 
therapy. Another two patients received radiation be- 
cause of an initial diagnosis of malignancy; however, 
their masses subsequently proved to be benign. 

Because the population we serve is very mobile, 
follow-up was incomplete. However, we know that 14 
of the 37 patients with diagnosed malignancy died 
within 12 months (Table IX). In this group were 
seven of eight patients with metastatic lymph node 
involvement, and three of four patients with embry- 
onal cell tumors. 

SELECTING DIAGNOSTIC PROCEDURES 

When first presented with a patient who has a 
mediastinal mass, the physician faces the problem of 
selecting helpful diagnostic procedures. The litera- 
ture, in which a series of surgical patients is 
analyzed retrospectively, demonstrates that nearly 
all primary mediastinal masses require tissue exam- 
ination to establish the diagnosis (14). The greatest 
value of diagnostic investigation is that it can differ- 
entiate between secondary and primary masses. 
Aneurysms, other cardiovascular lesions, hernias, 
and metastatic masses are frequently defined by 
contrast studies and limited biopsy procedures. 
Contrast studies— including examination of the 
barium-coated alimentary tract and angiography— 
may also be of value in determining the extent to 
which the mass involves adjacent mediastinal struc- 
tures. As newer diagnostic techniques are devel- 
oped, including echography, nuclear scanning, spe- 
cific organ function testing, and more specific im- 
munoserological testing, their usefulness in evaluat- 
ing mediastinal masses must be assessed. Medico- 
legal considerations, teaching value, and research 
benefits of new techniques must be balanced against 
the cost effectiveness of these techniques when a 
battery of diagnostic procedures is planned to evalu- 
ate a mediastinal mass. 

If the preliminary workup does not provide a spe- 
cific diagnosis for a mediastinal mass, surgical ex- 
ploration should be performed. The goals of surgery 
are to provide the specific histological diagnosis 
upon which to base a prognosis; to relieve symp- 
toms; to prevent complications (15); and to ablate 
malignancies. 

The most useful and definitive surgical approach 
for middle and posterior mediastinal masses is the 
lateral thoracotomy. Although limited access to the 



anterior mediastinum can be gained through the 
cervical approach, anterolateral thoracotomy, or the 
parasternal route, we usually use median sternot- 
omy, which provides optimal exposure for resection. 
Through the median sternotomy we also gain a good 
opportunity to obtain representative tissue for biopsy 
and to remove the greatest mass of tissue if debulk- 
ing is indicated. The procedure makes it easier to 
avoid injuring vital structures and to handle compli- 
cations (including use of cardiopulmonary bypass, if 
needed). The median sternotomy incision is usually 
less painful to the patient than a lateral thoracotomy, 
and allows ample exposure for the physician to ac- 
curately mark the borders of residual tumor with 
silver clips, which may facilitate subsequent radia- 
tion therapy. 

The most frustrating problem generated by sur- 
gery for mediastinal masses is the difficulty of inter- 
preting histology, especially on a frozen section 
basis. Interpretation is difficult because: 

• it is often hard to obtain representative tissue 
samples. 

• subtle histological criteria differentiate between 
specific entities in categories such as lymphoepithe- 
lial tissue. 

• pathologists have limited experience with rare or 
unusual mediastinal masses. 

• variations in the stages of the disease cloud the 
classic histological picture. 

• tissue may undergo secondary alterations by infec- 
tion, necrosis, radiation, chemotherapy, or trauma. 

With the growing interest in use of immunother- 
apy for controlling solid malignant tumors, the role 
of surgery in managing tumors is changing {16-19). 
In "solid tumor therapy" and "combination ther- 
apy," several therapies are combined to accomplish 
a step-by-step diminution of the tumor. Combination 
therapy may include surgery for "debulking" the 
localized malignant tissue, radiation to sterilize the 
tumor bed, chemotherapy to diminish the metastatic 
load, and specific or nonspecific immunotherapy to 
control or eradicate small quantities of residual 
tumor. 

CONCLUSIONS 

Our review of the surgical management of medias- 
tinal masses at Naval Regional Medical Center San 
Diego has enabled us to better define some continu- 
ing problems and has stimulated our interest in solv- 
ing those problems. We found that the diagnostic 
workup of a mediastinal mass is most productive 
when a variety of contrast studies and limited biopsy 



Volume 68, July 1977 



25 



procedures are employed to define secondary and 
primary masses. These studies may also help assess 
whether the mass involves adjacent structures. A 
complete surgical exposure is then essential to 
acquire representative tissue samples to establish a 
correct histological diagnosis, preferably by using 
frozen sections. Resectable masses should be re- 
moved. In some cases of invasive malignancy, the 
physician should consider surgically reducing the 
tumor to facilitate subsequent adjunctive therapy. 

REFERENCES 

1. Blades B: Mediastinal tumors. Ann Surg 123:749-765, 
1946. 

2. Harrington SW: Intrathoracic extrapulmonary tumors. 
Postgrad Med 6:6-21, 1949. 

3. Sabiston DC, Scott HW: Primary neoplasms and cysts of 
the mediastinum. Ann Surg 136:777-797, 1952. 

4. Ringentz MD, Lidholm SO: Mediastinal tumors and cysts. 
J Thorac Surg 31:458-487, 1956. 

5. Daniel RA, Diveley MD, Edwards WH, et al: Mediastinal 
tumors. Ann Surg 151:783-795, 1961. 

6. Patcher MR, Lattes R: Uncommon mediastinal tumors. Dis 
Chest 43:519-528, 1963. 

7. Oldham HN, Sabiston DC: Primary tumors and cysts of the 
mediastinum. Arch Surg 96:71-75, 1968. 



8. Strug LH, Leon W, Carter R: Primary mediastinal tumors. 
Am Surg 34:5-14, 1968. 

9. Grosfeld JL, Weinberger M, Kilman JW, et al: Primary 
mediastinal neoplasma in infants and children. Ann Thorac Surg 
12:179-190, 1971. 

10. Oldham HN: Mediastinal tumors and cysts. Ann Thorac 
Surg 11:246-275, 1971. 

11. Conkle DM, Adkins RB: Primary malignant tumors of the 
mediastinum. Ann Thorac Surg 14:553-567, 1972. 

12. Pokorny WJ, Sherman JO: Mediastinal masses in infants 
and children. J Thorac Cardiovasc Surg 68:869-875, 1974. 

13. Burkell CC, Cross JM, Kent HP, et al: Mass lesions of the 
mediastinum. Curr Probl Surg, June 1969, pp 1-57. 

14. Joseph WL, Murray JF, Mulder DG: Mediastinal 
tumors— problems in diagnosis and treatment. Dis Chest 50:150- 
159, 1966. 

15. Haller JA, Shermeta DW, Donahoo JS, et al: Life-threat- 
ening respiratory distress from mediastinal masses in infants. 
Ann Thorac Surg 19:364-370, 1975. 

16. Burke WA, Burford TH, Dorfman RF: Hodgkin's disease 
of the mediastinum. Ann Thorac Surg 3:287-296, 1967. 

17. Morton DL, Holmes EC, Eilber FR, et al: Immunological 
aspects of neoplasia: a rational basis for immunotherapy. Ann 
Intern Med 74:587-604, 1971. 

18. Eilber FR, Nizze JA, Morton DL: Sequential evaluation of 
general immune competence in cancer patients: correlation with 
clinical course. Cancer 35:660-665, 1975. 

19. Holmes EC: Immunology and lung cancer. Ann Thorac 
Surg 21:250-258, 1976. 



I DON'T MISS 

Febrile Illnesses Leading to Hospital 
Admissions in Indonesia 



In Vietnam, American military 
physicians found it hard to differen- 
tiate between malaria, Salmonella 
infection, scrub typhus, leptospiro- 
sis, and group B arbovirus infection 
on the basis of clinical signs and 
symptoms, and common clinical 
laboratory tests. To find out wheth- 
er bacteriological and serological 
methods are useful and clinically 
practical for diagnosing these seri- 
ous febrile illnesses, and to better 
define which febrile illnesses are 
prevalent in Indonesia, Naval Medi- 
cal Research Unit No. 2 scientists 
studied 741 patients admitted to 
seven Jakarta hospitals with fevers 
of unknown origin. The findings 
were reported in the American 
Journal of Tropical Medicine and 
Hygiene [25(1):116-121, Jan 1976]. 

Diagnoses were established for 
248 of the 741 patients studied. 



Bacteremia due to Salmonella typhi 
(150 patients), S. enteritidis (36 pa- 
tients), or both (2 patients) was 
common in children and adults. 
Serological evidence of Salmonella 
infection was found in another 130 
patients with no bacteremia. 

Serological evidence of arbovirus 
infection was common in children, 
most of whom did not present with 
distinctive clinical signs and symp- 
toms except for petechiae and 
purpura. Malaria was found in 12 
adults. Little serological evidence 
was found for rickettsial, leptospi- 
ral, Brucella, Toxoplasma gondii, 
and a number of other infections. 
The researchers concluded that 
enteric fevers and arbovirus infec- 
tions are the most common causes 
of fever requiring hospitalization in 
Jakarta. 

Because clinical signs and symp- 



toms were generally nonspecific, 
bacteriological and serological tests 
helped greatly to establish accurate 
diagnoses. For example, examining 
physicians incorrectly suspected S. 
typhi infection in 45% of 94 patients 
who were found to have significant 
arbovirus antibody titers. These pa- 
tients were diagnosed incorrectly 
because people suffering from sal- 
monellosis and arbovirus infections 
often exhibit the same symptoms. 
Serological testing for high or rising 
antibody titer was not sufficient by 
itself to establish the diagnosis of 
enteric fever — blood cultures were 
more reliable for establishing the 
presence of salmonellosis, and also 
provided a way to test for antibiotic 
resistance. 

"Febrile Illnesses Resulting in 
Hospital Admission: A Bacteriologi- 
cal and Serological Study in Jakarta, 
Indonesia," by Karl E. Anderson 
and associates is available from 
U.S. Naval Medical Research Unit 
No. 2, APO San Francisco 96263. 
Ask for Report No. TR-693. 



26 



U.S. Navy Medicine 



Pulp Response to Citric Acid Cavity Cleanser 



CAPT William R. Cotton, DC, USN 
Richard L. Siegel, D.D.S. 



It is generally accepted that acid etching agents 
enhance the bonding and adaptation of composite 
restorative material to enamel (i). However, recent 
attempts to bond restorative material to dentin have 
been unsuccessful because no adhesives currently 
available will form water-resistant bonds to dentin 
that are comparable to the strong bonds formed with 
enamel (i). 

Acid etchants are commercially available as cavity 
cleansers applied directly to dentin to remove debris, 
spalled enamel, and spalled dentin. Most acid cavity 
cleansers contain citric or phosphoric acid (2). 
Although there are conflicting reports on dental pulp 
response to a one-minute application of phosphoric 
acid on freshly exposed dentin (3,4), there is 
evidence that pretreating a cavity with phosphoric 
acid intensifies pulp reaction to composite resins (5). 
With one exception (6), available evidence indicates 
that pretreating exposed dentin with citric acid for 
one minute also intensifies pulp response to com- 
posite resins [5, 7,8) ; however, the effect of citric acid 
on the pulp has not been studied. This investigation 
evaluated the effect of citric acid cavity cleanser on 
human dental pulp. 

MATERIALS AND METHODS 

Class V cavities were prepared on 45 caries-free 
first bicuspid teeth which were scheduled to be ex- 
tracted for orthodontic purposes. Patients ranged in 
age from 10 to 19 years, with mean age of 11.9 years. 
A 5 -mm- wide cavity was cut in the cervical third of 
the facial surface of each tooth with a 230 or 33 Va 



CAPT Cotton is chairman of the Dental Sciences Department, 
Naval Medical Research Institute, National Naval Medical Cen- 
ter, Bethesda, Md. 20014. Dr. Siegel is in private practice at 8221 
W. Silver Spring, Milwaukee, Wise. 53218. 

This paper was presented at a symposium, "Pulp and Dentin 
Response to Material Systems Using Etching Agents," during 
the Annual Session of the International Association for Dental 
Research, Miami Beach, Fla. , on 26 March 1976. The project was 
supported by the Naval Medical Research and Development 
Command under Research Task No. M00095.PN.04.3012. 



carbide bur, at 200,000 rpm, using an air-water 
spray coolant. 

A cotton pellet soaked in citric acid cavity cleans- 
er* was placed in the 23 experimental cavities for 
two minutes. Each cavity was flushed with a gentle 
stream of tepid water and dried with a cotton pellet. 
The 22 control cavities, prepared in contralateral 
bicuspids, were also flushed with water, but the 
cleanser was omitted. All teeth were restored with a 
fresh mixture of zinc oxide and eugenol (ZnOE). The 
teeth were extracted 1 to 4, 7 to 13, or 21 to 35 days 
after treatment. 

After the specimens were fixed in formalin, they 
were demineralized in 20% formic acid, embedded 
in paraffin, sectioned serially and stained with 
hematoxylin and eosin. Histologic evaluation was 
based on criteria established by the American Dental 
Association (9). 

RESULTS 

As shown in the table, responses were seen more 
frequently in teeth treated with cavity cleanser than 
in control teeth, except that the frequency of hemor- 
rhage and reparative dentin was the same for both 
groups. The difference in the frequency of responses 
between the control and experimental teeth was not 
statistically significant except for deep pulp re- 
sponse, which occurred significantly {P< 0.01) more 
often in teeth treated with cavity cleanser than in 
control teeth. 

The degree of cellular displacement into the 
dentinal tubules (Figure 1) and the degree of super- 
ficial inflammatory response (Figure 2) and deep in- 
flammatory response (Figure 3) were initially greater 
in the teeth treated with cavity cleanser, but de- 
creased with time. The deep inflammatory response 
in the 1- to 4-day group was significantly {P<0.01) 
more intense in teeth treated with cavity cleanser 
(Figure 3). 



♦Epoxylite 9060 Cavity Cleanser, Lee Pharmaceuticals, South El 
Monte, Calif. 91733. 



Volume 68, July 1977 



27 



CLINICAL AND HISTOLOGIC DATA 



Specimen 
treatment 




Number of 
specimens (45) 


Mean 

postoperative 

interval 


Mean remaining 
dentin thickness 


Specimens 
with cellular 
displacement 


Specimens 
with induced 
reparative 

dentin 


Citric acid 
cavity cleanser 
+ ZnOE 




6 

7 

10 


2.5 days 
10.7 days 
29.0 days 


1.38 mm 
1.44 mm 
1.36 mm 


2 (33.3%) 
2 (28.5%) 
(0.0%) 


(0.0%) 

(0.0%) 

1 (10.0%) 




Total 


23 






4 (17.4%) 


1 (4.3%) 


ZnOE 




6 

8 
8 


2.5 days 
10.5 days 
29.0 days 


1 .49 mm 
1.38 mm 
0.95 mm 


2 (33.3%) 
0(1.0%) 
(0.0%) 


(0.0%) 

(0.0%) 

1 (12.5%) 




Total 


22 






2(9.1%) 


1 (4.5%) 



*P<0.01 



Chi square with Yates' correction (df = 1) 0.145 



0.001 



DISCUSSION 

Results of this study indicate that citric acid cavity 
cleanser caused an initial deep inflammatory re- 
sponse which decreased with time. The cleanser's 
acidity, pH 3.2, probably caused this early deep re- 
sponse. 

Our findings support observations reported by 
other researchers. Eriksen (7), who studied the com- 
bined effect of citric acid pretreatment and com- 
posite restorations, found that in cavities prepared in 
monkey teeth pretreatment with a 45% citric acid 
solution increased pulp response to composite 
resin. Stanley et al (5) found that a 50% citric acid 
solution intensified and prolonged the severity of 
pulp reactions when the acid solution was used with 
composite resin; they also found that composite resin 
by itself is toxic to the pulp. 

Although there was no indication from the present 
study that citric acid cavity cleanser causes an irre- 
versible pulp reaction, sound clinical judgment dic- 
tates that direct application of citric acid cleanser to 
freshly cut dentin should be avoided. Because of its 
harmful effect on the pulp, citric acid cavity cleanser 
is not justified for the purpose implied by its name: 
to cleanse the cavity. 

Citric acid cavity cleanser can be applied with rela- 
tive safety to dentin protected by an adequate base 
or liner {10). However, a base or liner would prevent 
the cleanser from acting on the dentin, in which case 
the citric acid cleanser would be acting primarily to 
etch the enamel walls. 



SUMMARY 

Citric acid cavity cleanser is toxic to human dental 
pulp when applied to freshly cut dentin. The cleanser 
initially caused a significantly greater frequency and 
intensity of deep inflammatory responses, which de- 
creased with time. Other histologic signs showed a 
similar, although not significant trend: the incidence 
and intensity of responses were greater in the pulps 
subjacent to cavities treated with citric acid. 

REFERENCES 

1. Dogon IL, Silvertone LM: Acid etch techniques. Br Dent J 
138:261-264, 1975. 

2. Lee HL Jr., Orlowski JA, Scheidt GC, Lee JR: Effects of 
acid etchants on dentin. J Dent Res 52:1228-1233, 1973. 

3. Goto G, Jordan RE: Pulpal effects of concentrated phos- 
phoric acid. Bull Tokyo Dent Coll 14:105-112, 1973. 

4. Retief DH, Austin JC, Fatti LP: Pulpal response to phos- 
phoric acid. J Oral Pathol 3:114-122, 1974. 

5. Stanley HR, Going RE, Chauncey HH: Human pulp re- 
sponse to acid pretreatment of dentin and to composite restora- 
tion. J Am Dent Assoc 91:817-825, 1975. 

6. Lee HL, Cupples AL, Schubert RJ, Swartz ML: An adhe- 
sive dental restorative material. J Dent Res 50:125-132, 1971. 

7. Eriksen HM: Pulpal response of monkeys to a composite 
resin cement. J Dent Res 53:565-570, 1974. 

8. Vojinovic O, Nyborg H, Brannstrom M: Acid treatment of 
cavities under resin fillings: Bacterial growth in dentinal tubules 
and pulpal reactions. J Dent Res 52:1189-1193, 1973. 

9. Guide to Dental Materials and Devices, 8th ed. Chicago: 
American Dental Association, 1976, pp 205-206. 

10'. Eriksen HM: Protection against harmful effects of a 
restorative procedure using an acid cavity cleanser. J Dent Res 
55:281-284, 1976. 



28 



U.S. Navy Medicine 



Specimens 
with 

superficial 
response 


Specimens 
predominating 
in acute eel Is 
(superficial) 


Specimens 
with 
deep 
response 


Specimens 
predominating 
in acute cells 
(deep) 


Specimens 

with 

hemorrhage 


1 (16.6%) 
1 (14.3%) 
(0.0%) 


1 (16.6%) 
1 (14.3%) 
(0.0%) 


5 (83.3%) 

2 (28.6%) 

3 (30.0%) 


2 (33.3%) 
2 (28.6%) 

(0.0%) 


2 (33.3%) 
2 (28.6%) 
4 (40.0%) 


2 (8.7%) 


2 (8.7%) 


10 (43.5%) 


4 (17.4%) 


8 (34.8%) 


1 (16.6%) 
(0.0%) 
(0.0%) 


1 (16.6%) 
(0.0%) 
(0.0%) 


(0.0%) 

1 (12.5%) 
(0.0%) 


(0.0%) 

1 (12.5%) 
(0.0%) 


3 (50.0%) 
3 (37.5%) 
2 (25.0%) 

8 (36.4%) 


1 (4.5%) 


1 (4.5%) 


1 (4.5%) 


1 (4.5%) 



0.001 



0.001 



7.241 * 



0.573 



0.040 




N = 6 



Cleanser 
Control 



N = 



-4 Days 

t=0.99 

p>0.05 



7-I3 Days 

t=l.33 
p>0.05 



N = I0 M = 8 

-nmn - - 



21-35 Days 

1 = 
p>0.05 



1.5- 



eli.o 






FIGURE 1. Cellular displacement into the dentinal tubules in Jj 
response to citric acid cavity cleanser, arbitrarily graded on a — 
scale of to 3 (9). § 



0,5 




L ^L- 



S Cleanser 
■ Control 



I-4 Days 

t=3.5l 
p<0.0l 




Cleanser 
Control 




7-l3Days 
t=[.00 
p>0.05 



2l-35Days 
t=l.63 
p>0.05 



FIGURE 3. Deep inflammatory response to citric acid cavity 
cleanser, arbitrarily graded on a scale of to 4 (9). 



7- 13 Days 
t=l.00 

p>0.05 



ZI-35 Days 
t=0 

p>0.05 



FIGURE 2. Superficial inflammatory response to citric acid 
cavity cleanser, arbitrarily graded on a scale of to 4 (9). 



Volume 68, July 1977 



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